Download ADMINISTRATION BY INJECTION POLICY

ADMINISTRATION BY INJECTION POLICY – INTRAVENOUS,
INTRAMUSCULAR AND CENTRAL LINES
This policy should be read in conjunction with the Syringe Driver Policy,
Medicines, Record Keeping and Records Management Policy, Consent policy
for Mental/Community Health Services and Healthcare (Clinical) Waste Policy
Version:
5
Ratified By:
Senior Managers Operational Group
Date Ratified:
November 12 (February 2014 minor
amendments)
Title of Author:
Senior Nurse for Clinical Practice
Title of Responsible Committee/Group:
Medicines Management
Date Issued:
November 12 (February 2014 minor
amendments)
Review Date:
October 2015
Relevant Staff Group(s):
Registered Nurses in CH and MH
Directorates, Medical staff working at
inpatient units and community
hospitals, Registered Nurses working
in the community for CH Directorate,
Physiotherapists in CH Directorate,
STARS, CPNs
This document is available in other formats, including easy read summary versions and other
languages upon request. Should you require this please contact the Equality and Diversity
Lead on 01278 432000
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DOCUMENT CONTROL
Reference
Version
NV/Nov12/AbIP 5
Status
Final
Author
Senior Nurse for Clinical Practice
Intravenous: Merge of Policies for Intramuscular Injections and
Management of Central Lines, training section updated, inclusion of
depot injections policy, Addition of clinical audit standards, Inclusion
Amendments
of recommendations of the equality impact assessment, inclusion of
Removal of PICC lines, Care and Management of Implanted Venous
Access Devices and Cytotoxic Infusion Pumps – Disconnection and
Disposal
Document objectives: Somerset Partnership NHS Foundation Trust is committed to
ensuring safe clinical practice in the administration of intravenous and intramuscular
drugs through the provision of appropriate training and guidelines for staff to ensure
safe clinical practices.
Intended recipients: As depicted on front page
Committee/Group Consulted: Community Hospital Best Practice Group, Clinical
Policy review Group, Clinical Governance Group
Monitoring arrangements and indicators:
This policy will be reviewed every 3 years or as required to ensure compliance with
nationally recommended policy and best practice.
Training/resource implications: Training already provided by the Learning and
Development Department for Medicines Management, Intramuscular, Intravenous
Drug Therapy and Management of Central lines
Clinical Governance
Date: October 2012
Approving body and date
Group
February 2014
Formal Impact Assessment
Impact Part 1
Date: November 2012
Ratification Body and date
Senior Managers
Operational Group
Date: November 2012
February 2014
Date of issue
November 12 (February 2014 minor amendments)
Review date
October 2015
Contact for review
Senior Nurse for Clinical Practice
Lead Director
Chief Operating Officer
CONTRIBUTION LIST Key individuals involved in developing the document
Name
Designation or Group
Nina Vinall
Senior Nurse for Clinical Practice
Claire Marks
District Nurse Lead
Pip Beddingfield
Clinical Trainer for the training department
All Members
Medicines Management
All Members
Clinical Policy Review Group
All Members
Clinical Governance Group
All Members
Senior Managers Operational Group
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Mary Martin
Out of Hours Lead and Interim Lead for District Nursing
Karen Hochmuth
Chief Pharmacist
Paul Watts
Consultant Nurse for psychological therapies
Jill Leppard
Lead Nurse for Medicines Management (Mental Health Services)
Jaime Denham
Clinical Skills Facilitator
Andrew Sinclair
Lead for Equality and Diversity
Suzi Davies
Clinical Skills Facilitator
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CONTENTS
Section
Page
Doc
Document Control
2
Cont
Contents
4
1
Introduction
5
2
Purpose and Scope
8
3
Duties and Responsibilities
8
4
Explanations of Terms Used
10
5
Statement of Policy and Guidance
10
6
Training Requirements
11
7
Equality Impact Assessment
12
8
Monitoring Compliance and Effectiveness
13
9
Counter Fraud
13
10
Relevant Care Quality Commission (CQC) Registration
Standards
13
11
References, Acknowledgements and Associated Documents
14
12
Appendices
15
Appendix A
Administering IV Drugs and Fluids
16
Appendix B
Flow chart for red flag drugs
24
Appendix C
Intramuscular Injections
25
Appendix D
Central Line Management
38
Appendix E
Cytotoxic Infusion Pumps – Disconnection and Disposal
63
Appendix F
Competency assessment for intravenous drug administration
69
Appendix G
Competency assessment for the care of central lines
75
Appendix H
Audit Standards for Injectable Medicines
82
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1.
INTRODUCTION
1.1
Somerset Partnership NHS Foundation Trust is committed to ensuring safe
clinical practice in the administration of intravenous (IV) and intramuscular
(IM) drugs through the provision of appropriate training and competency
assessment for staff to ensure safe clinical practices.
1.2
The use of injectable medication has many healthcare benefits for patients.
The complexities associated with the prescription, preparation and
administration of injectable medicines means that there are greater potential
risks for patients than for other routes of administration. Safe systems of
work are required to minimise these risks (NPSA 2007).
1.3
Each nurse, midwife or health visitor is personally accountable for their
practice and professional accountability in line with Nursing and Midwifery
Code: Standards of conduct, performance and ethics for nurses and
midwives (2008).
1.4
Staff should ensure the patient is able to understand the information given to
them and are able to give their informed consent. This may necessitate the
use of a professional interpreter and the translation of written information. A
capacity assessment should be considered for those patients who are
unable to consent to the procedure and reference should be made to the
relevant Trust policy (refer to the consent policy for your service, Consent
and Capacity to Consent to Treatment Policy Mental Health Services or
Consent to Examination and Treatment Community Health Services).
1.5
The administration of any medication is an opportunity for assessment and
information exchange with the patient and their carers (where appropriate).
Preparation should include an assessment to see if the physical and /or
mental health of the patient has changed since the previous contact. Any
beneficial effects or side-effects experienced since the last injection should
be considered and questions asked of the patient and their carer (if
appropriate) to elicit any concerns or information needs.
1.6
For all ambulatory care patients please use the Ambulatory Care
Documents.
1.7
Staff must consider the gender, beliefs and religious backgrounds of patients
when approaching and gaining consent to administer an injection. For
example, a patient may request same gender as the patient. This may not
always be possible or practical in an emergency situation.
Labelling of syringes prior to administration
1.8
All injections should be labelled immediately after preparation, except for
syringes intended for immediate push (bolus) administration by the person
who prepared them. Under no circumstances should an operator be in
possession of more than one unlabelled syringe at any one time, nor must
an unlabelled syringe be fitted to a syringe driver or similar device National
Patient Safety Agency (NPSA) 2007. Where one IV drug and one IV Sodium
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Chloride 0.9% (normal saline) flush are prepared a pre-printed label can be
used to identify the IV normal saline flush. Pre-printed labels will only be
available for Sodium Chloride 0.9%. When approaching a patient with two IM
injections for administration, e.g. rapid tranquilisation, then both must be
labelled (refer to rapid tranquilisation guidelines).
Intravenous
1.9
All practitioners involved in IV drugs administration must adhere to the
guidelines of their professional bodies and must follow the flow chart when
handling ‘red’ drugs (Appendix B).
1.9.1
The term intravenous (IV) refers to drugs administered using both peripheral
and central venous access devices.
1.9.2
This policy should be read in conjunction with the following trust policies and
protocols
•
•
•
•
•
•
•
•
•
1.9.3
Medicines Policy
Medical Devices
Blood & Blood Components Transfusion Policy
Infection Control
Healthcare (Clinical) Waste Policy
Safe handling of sharps policy
Indwelling devices policy
Untoward Events Reporting Policy
Protocol for Assessing Competencies and Clinical Practice
This policy should be read in conjunction with the following National Patient
Safety Agency Alerts
•
•
Promoting Safer Use of Injectable Medicines (March 2007)
Risks with Intravenous Heparin Flush Solutions ( April 2008)
Intramuscular
1.10
Evidence has identified a potential risk to patients from incorrect injection
procedure. Somerset Community Health has a responsibility under clinical
governance to examine and manage that risk.
1.10.1 It may be due to the misconception that administering an injection is a basic
task that it has traditionally been overlooked by continuing professional
development programmes (Diggle 2007), resulting in nurses relying on skills
which they acquired during their original training (Chiodini 2000).
1.10.2 Nurses have a duty to deliver care based on current evidence and best
practice (NMC 2008). However, the traditional method of verbalising
information down through generations of nurses has exposed clinical
practice to rituals (Wynaden et al 2005).
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1.10.3 The Royal Marsden Hospital Manual (Dougherty and Lister 2011) recognises
only one particular site for intramuscular injections. This policy will raise
awareness of intramuscular sites and thereby reduce the risk of potential
complications.
1.10.4 It is essential to consider whether an injection is justified (Nicoll and Hesby
2002) reaffirmed by World Health Organisation’s (WHO) policy that injections
must be safe and appropriate (WHO 2006).
1.10.5 There is a nationally recognised ‘manual’ for depot medication also available
(Feetam and White 2011) available at www.hull.ac.uk/injectioniguide for staff
to refer to.
1.10.6 The purpose of an intramuscular injection is to deliver medication into the
muscle layer beneath the subcutaneous tissue:•
for rapid systematic uptake of a drug (Greenway 2004)
•
when prolonged action is required (Hunter 2008)
•
enables relatively large doses to be absorbed into well perfused muscle
(Workman 1999)
1.10.7 Certain drugs are only licensed to be administered intramuscularly to prevent
local irritation or inflammation or those drugs that may be destroyed in the
gastrointestinal tract (Nicoll and Hesby 2002). These include:•
•
biological eg. vaccines, toxoids and immune globulins
nonbiologicals eg. antibiotics and depot formulations such as
neuroleptics, hormonal agents and cancer treatments allowing slow
release. They are often oily solutions with potential to be irritating
(Nicoll and Hesby 2002)
1.10.8 Patient related reason for giving an injection:•
•
•
inability to take medication orally (Higgins 2004)
patient’s preference for injection believing it to be more effective (Nicoll
and Hesby 2002)
reluctance to take medication necessitating an injection, but still
considering the patients’ rights and need for medication (Nicoll and
Hesby 2002). This is more likely in the mental health setting (Cocoman
and Murray 2008)
Central Line Management
1.11
This document outlines recommended practices relevant to the management
of central venous access devices; Peripherally Inserted Central Catheters
(PICC), Tunnelled Hickman Lines and Implanted Venous Access Devices
(Portacath).
1.11.1 It follows guidance issued from the Royal College of Nursing Standards for
infusion therapy (2010) and Mallet and Dougherty (2008) Royal Marsden
Hospital Manual of Clinical Nursing Procedures. The guidance will also
reflect management differences recommended from the three main acute
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hospitals serving Somerset, namely, Musgrove Park Hospital (MPH), Yeovil
District Hospital (YDH) and Royal United Hospital (RUH) which are detailed
on page 66.
1.11.2 Due to the varying differences at the three main acute hospitals, staff must
ensure they follow the patient’s own care plan for management of their line
which has been developed in conjunction with their specialist Nurse or
Consultant. If the patient does not have a valid care plan, ensure the
guidance recommended on page (may need to check this page number
throughout the doc) of this policy and must be followed for each patient
dependent on the referring acute hospital.
1.11.3 Practitioners undertaking this clinical skill must ensure they are trained and
have been assessed as competent in the management of central lines. The
training and competency assessment received must cover the main aspects
of central line management including, flushing, dressing change,
administration of medicines and blood sampling.
1.11.4 The Trust acknowledges and respects the diverse needs of its staff and will
respect these at all times when implementing this policy. This includes
respecting the privacy and dignity of patients at all times. The reasons for the
intervention should be clearly explained to the patient and this may
necessitate the use of a professional interpreter.
2.
PURPOSE AND SCOPE
2.1
The purpose of this policy is to ensure the safe administration of injectable
drugs and additives and:•
•
•
•
•
•
•
•
3.
informing all practitioners of their responsibility in the safe and effective
administration of medicines and fluids by injection
ensuring that all persons who undertake IV medicine administration
have demonstrated that they are competent to do so
ensuring staff are aware of current evidence surrounding injection
procedures
ensuring staff are familiar with all potential injection sites
highlighting the importance of accurately locating intramuscular
injection sites
raising awareness of possible complications
updating skills and technique to ensure patient safety and protect own
accountability
sharing knowledge to achieve best practice (NMC 2008)
DUTIES AND RESPONSIBILITIES
All Staff
3.1
Intravenous drugs may only be administered by registered practitioners who
have completed appropriate training (IVs and central lines) and have
demonstrated that they are competent to safely administer intravenous
medication to patients following completion of the relevant competency
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assessments (Appendices E and F). Staff must attend or complete the
mandatory anaphylaxis training annually.
The Prescriber
3.2
It is the responsibility of the prescriber to ensure that medicines are
prescribed in accordance with Trust approved medicines. For the
Community Health Services this is in accordance with NHS Somerset
Formulary. They should only administered by injection when no other route
is suitable.
This decision will be based upon;
•
the availability of other routes
•
the clinical condition of the patient
•
the available formulations of the specific medicine required
•
relevant NICE or Trust clinical guidelines
3.2.1
It is the responsibility of the prescriber to ensure that intravenous
prescriptions are reviewed regularly and at least once every 24 hours, unless
otherwise clinically indicated
3.2.2
The prescription must be changed to a less hazardous route at the earliest
clinically appropriate opportunity.
3.2.3
All intravenous antibiotics must be reviewed after 48 hours for consideration
of converting to the oral route. All staff are responsible for ensuring this
review and to clearly document the rationale for the extended duration of
treatment.
3.2.4
Any nurse working in a community setting who is asked to prescribe IV
medication (red flag drugs) should first confirm with their line manager and
must follow the flow chart on page 22.
Clinical Pharmacists
3.3
The Clinical Pharmacists and Technicians provide a broad based clinical
advisory and medicine management service for community hospitals through
the service level agreements in place with the relevant Trust pharmacy
departments.
The service includes:
•
•
•
•
•
3.3.1
prescription review
medicine choice
pharmaceutical education and training
information regarding storage, administration and use of medicines
implementation and use of medicine management systems for
ordering, storing, administration and supply of medicines
•
preparation of IV fluids with additives
The hospital pharmacies can be contacted to obtain advice and respond to
specific enquiries raised by health care professionals regarding all aspects of
drug therapies including:
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•
•
•
•
•
•
•
•
•
•
•
4.
method of administration
diluents and infusion fluids
drug stability
delivery systems e.g. pump
drug compatibility
rate of administration
contraindications and side effects
interactions
unlicensed drugs and their use
preparation of anaphylaxis boxes
provision and updating of monographs in clinical areas
EXPLANATIONS OF TERMS USED
Central Line – sited centrally with the tip sitting at the entrance of the right
atrium
Hickman Line – trade name for central line. Extends into the deeper veins
Intravenous – within a vein
Intramuscular – into a muscle
PICC Line – Peripherally (forearm/hand) Inserted Central Catheter
SmPC – Summary of Product Characteristics
Portacath – Implanted Venous Access Device
Personal Protective Equipment (PPE) – should be worn when all other
measures are inadequate to control exposure. It protects only the wear,
while being worn and includes such items as gloves, aprons, respirators and
eye goggles.
Cytotoxic – literally means toxic to cells and hence cytotoxic medications
will kill cells.
5.
STATEMENT OF POLICY AND GUIIDANCE
Authorisation of Drugs for Administration
5.1
The Trust does not provide a defined list of approved drugs for
administration and expects staff to practice only within their sphere of
competency and in accordance with the Trust Medicines Policy and
Prescribing Formulary and the Nursing and Midwifery Council Code of
Conduct 2008.
5.1.1
Any nurse working in a community setting who is asked to administer IV
medication (red flag drugs) should first confirm with their line manager and
must follow the flow chart at Appendix B
Criteria for assessors
5.2
To be able to assess an individual practitioner’s knowledge and
competencies for IV drug administration the assessor must:
•
•
•
hold a recognised teaching and assessing qualification
be a registered health care professional
be confident and competent in performing the skill
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•
•
•
practice the skill regularly
have sound knowledge of the relevant policies and procedure
have a thorough understanding of the competency based assessment
process
Administration/ Recommendations for Safe Practice
5.3
In accordance with the Trust’s Medicine Policy it is recommended that the
administration of IV drugs and intravenous additives should be undertaken
by a registered nurse who is competent and will be checked by a second
member of the nursing team, preferably a Registered Nurse.
5.3.1
Registered practitioners working alone in the community must have
demonstrated the necessary knowledge and competence to administer
medicines by this route and should, where possible, have the drug checked
by another individual who knows the patient. This could be a parent, carer
or the patient. At a minimum any dose calculation should be independently
checked (RCN 2010). Competency assessments for blood transfusions can
be found on the internet: www.npsa.nhs.uk
5.3.2
In accordance with Trust policy all blood transfusions should be administered
by a registered nurse who must have completed the IV training and the
blood transfusion training. Staff must be assessed as competent in both IVs
and blood transfusions in addition to a second responsible person, usually a
member of the nursing team.
5.3.3
When seeking information or a second check, the nurse should use the
appropriate source, including pharmacy for medicine information, and be
aware of the role and competence of any second person involved.
5.3.4
The administration of IV drugs must be carried out by a registered
practitioner; however student nurses who have been assessed as competent
during their training may act as the second checking person.
5.3.5
Controlled drugs may be administered intravenously in accordance with the
Trust’s Medicine Policy.
5.3.6
Appropriate personal protective equipment should always be used.
5.3.7
There are two main types of ampoules;
•
•
spot ampoules – always break away from the spot
ring cut ampoules – can be broken in any direction
6.
TRAINING AND ASSESSMENT OF COMPETENCE
6.1
The Trust will work towards all staff being appropriately trained in line with
the organisation’s Staff Mandatory Training Matrix (training needs analysis).
All training documents referred to in this policy are accessible to staff within
the Learning and Development Section of the Trust Intranet;
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6.2
All staff must complete the Trust Medicines Management training
programme, including newly qualified and newly appointed Registered
Nurses. Once attended training staff must be assessed as competent before
commencing medicines administration of any form or route. All staff must
have undertaken mandatory training in Anaphylaxis
6.3
Education and training will include theoretical knowledge and practical skills.
This will be followed by a period of supervised practice and formal
assessment of competence using the agreed Trust competency framework
and documentation as supplied by the training department.
Specialist training will be provided for staff who will be caring for patients with
an implanted venous access device. This will be on a named basis only. This
procedure is not to be undertaken otherwise. The training at present will be
delivered by the assigned hospital for the patient.
6.4
Competencies for Medicines Management (includes sub-cutaneous and
intramuscular administration), intravenous therapy and Management of
Central Line Catheters (PICC/Hickman) lines must be achieved prior to
unsupervised administration of IV therapy via central lines (refer to Appendix
E – Competency assessment for intravenous drug administration and
Appendix F Competency assessment for the care of Central Lines.
Competency assessment for implanted venous access devices will not be
necessary proving the Registered Nurse has proved competence in IV
administration and Care of Central Lines.
6.5
All training and competency records must be reviewed at appraisal. Records
must be maintained by the individual and the Department Manager. This
must include a record of how often this skill has been used in practice.
6.6
All staff should have access to further update training if it is required to
enable them to continue to practice competently. This should be considered
after periods of extended absence through sickness or maternity leave or
where lack of administration opportunities has compromised potential
competence.
6.7
Bank and agency staff who can provide written evidence of training and
competency may administer IV drugs
7.
EQUALITY IMPACT ASSESSMENT
7.1
All relevant persons are required to comply with this document and must
demonstrate sensitivity and competence in relation to the nine protected
characteristics as defined by the Equality Act 2010. In addition, the Trust has
identified Learning Disabilities as an additional tenth protected characteristic.
If you, or any other groups, believe you are disadvantaged by anything
contained in this document please contact the Document Lead (author) who
will then actively respond to the enquiry.
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8.
MONITORING COMPLIANCE AND EFFECTIVENESS
8.1
Any reported incidents via DATIX will be investigated and necessary actions
implemented.
8.2
An annual audit (Appendix H) will be undertaken to ensure compliance with
policy and practice. The audit results will be made available to and
monitored by the relevant Best Practice Groups and discussed at the Clinical
and Social Care Effectiveness Group.
9.
COUNTER FRAUD
9.1
The Trust is committed to the NHS Protect Counter Fraud Policy – to reduce
fraud in the NHS to a minimum, keep it at that level and put funds stolen by
fraud back into patient care. Therefore, consideration has been given to the
inclusion of guidance with regard to the potential for fraud and corruption to
occur and what action should be taken in such circumstances during the
development of this procedural document.
10.
RELEVANT CARE QUALITY COMMISSION (CQC) REGISTRATION
STANDARDS
The protocol encompasses the following outcomes of the NHS Regulations
(2010) published by the Department of Health.
Section
Information and involvement
Outcome
1
2
Personalised care, treatment
support
4
6
Safeguarding and safety
7
Respecting and involving people who
use services
Consent to care and treatment
Care and welfare of people who and
use services
Cooperating with other providers
8
9
Safeguarding people who use services
from abuse
Cleanliness and infection control
Management of medicines
Suitability of staffing
12
Requirements relating to workers
Quality and management
16
Assessing and monitoring the quality of
service provision
Records
21
Suitability of management
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11.
REFERENCES, ACKNOWLEDGEMENTS AND ASSOCIATED
DOCUMENTS
11.1
References
Education and Training Strategy – Somerset Primary Care Trust 2008
Good Practice Statement for the Preparation of Injections in Near Patient
Areas, including Clinical and Home Environments. NHS Scotland 2002
Injectable Drug Administration Guide UCL Hospitals. Edited by R Shulman et
Al, Blackwell Science 1998
Mallet, J. and Dougherty, L. 2011. 8th ed. Royal Marsden Hospital Manual of
Clinical Nursing Procedures. Wiley- Blackwell.
Medical Devices Agency Single Use Medical Devices: Implications and
consequence of re-use. MDA DB 2000(04) August 2000.
rd
Multiple Use of Injections 3 ed NHS Pharmaceutical Quality Control
Committee Nov 2004
NMC Code: Standards of conduct, performance and ethics for nurses and
midwives (2008)
NMC Standards for Medicines Management 2007, updated 2010
NPSA (2007) Patient Safety Alert No. 20 – Promoting Safer Use of Injectable
Medicines
NPSA Patient Safety Observatory Safety in doses: Medication Safety
Incidents in the NHS 2007 www.npsa.nhs.uk
RCN Standards for Infusion Therapy 2010
11.2
Cross reference to other procedural documents
Consent and Capacity to Consent to Treatment Policy (Mental Health
Services)
Consent to Examination and Treatment Policy (Community Health Services)
Healthcare (Clinical) Waste Policy
Infection Control Policy
Medicines Policy
Needlestick and Contamination Injury Policy
Rapid Tranquillisation Guidelines
Record Keeping and Records Management Policy
Syringe Driver Policy
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12.
APPENDICES
12.1
For the avoidance of any doubt the appendices in this policy are to constitute
part of the body of this policy and shall be treated as such. This should
include any relevant Clinical Audit Standards.
APPENDIX A – Protocol for administering IV drugs and fluids
APPENDIX B – Flow chart for red drugs
APPENDIX C – Intramuscular Injections
APPENDIX D – Central Line Management
APPENDIX E - Cytotoxic Infusion Pumps – Disconnection and Disposal
APPENDIX F – Competency assessment for intravenous drug
administration
APPENDIX G – Competency assessment for the care of central lines
APPENDIX H – Audit standards for safer use of injectable medicines
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APPENDIX A
ADMINISTERING IV DRUGS AND FLUIDS
1.
For the detail of the procedure, registered nurses should refer to the Royal
Marsden Manual of Clinical Nursing Procedures – Oxford Blackwell Science,
Eigth Edition.
1.1
A copy should be available in each clinical ward area in community hospitals
and in each health centre. Alternatively it can be found on the Somerset
Primary Care Trust intranet site:
http://nww.somersetpct.nhs.uk/cnp/content/contents.htm
Technical Information on Injectable Medicines
2.
In accordance with the NPSA Patient Safety Alert, Promoting the Safer Use
of Injectable Medicines (March 2007) the Trust must ensure that essential
technical information on injectable medicines is available and accessible to
healthcare staff in clinical areas at the point of use.
2.1
Some injectable medicines do not have a package insert providing essential
technical information about preparation and administration, or the
information is insufficient to fully meet the needs of all healthcare staff.
2.2
All staff administering IV medicine in Community Health Services will use the
Taunton and Somerset NHS Foundation Trust IV drug monograph details on
page 22, available for downloading and printing from
http://195.105.0.247/Directorate/Med/Pharmacy/Monographs/Index.htm
For Mental Health Services then access to Medusa via the Somerset
Partnership intranet.
2.3
It is the responsibility of the nurse administering the IV medication to ensure
that an up to date IV monograph is available and stored with the prescription
chart for each patient and referred to during the preparation of each dose.
2.4
On completion of the IV therapy the IV monograph should be destroyed and
not kept in the notes. If a patient has an adverse reaction or the version
needs to be traced, contact must be made with Taunton and Somerset NHS
Foundation Trust pharmacy to ascertain which version was used in
conjunction with the date of administration.
Routes and Methods for the Administration of IV Drugs
3.
IV drugs may be administered in the following ways;
•
•
•
•
•
•
intermittent bolus dose using cannulae /y connections
intermittent infusion
continuous infusion of proprietary pre-prepared drugs
addition to infusion fluids in bags, bottles or burette chambers
central venous catheter port
central lines triple lumen, quad lumen, drum catheter
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•
•
Hickman tunnelled lines and PICC lines (peripherally inserted central
catheters)
implanted devices (specific training will be required from the referring
area prior to using these devices)
Consideration should be given to using needle free connectable ports
where ever possible.
4.
The practitioner may only administer drugs via the methods for which they
have received education and training and for which the drugs have been
prescribed and are licensed.
4.1
Where drugs need to be given using a syringe pump or volumetric infusion
pump, the practitioner must have received education and training in the use
of that equipment.
4.2
When IV drugs are being administered via a pump for infusions the system
must be checked 15 minutes after commencing administration and then at
each drug round unless otherwise directed on the monographs. The infusion
must also be checked at each shift handover.
4.3
Changing of IV infusion lines must be carried out every 72 hours (RCN 2010)
unless the following applies:
•
•
•
if a drug is administered using the Central Venous Route this infusion
line must be changed every 72 hours
if a drug is being administered via an intermittent infusion the line, it
must be changed at every dose if disconnected between doses
for blood administration the line must be changed at least every 12
hours and immediately upon completion of the last unit
A peripheral cannula which has been inserted in an emergency
situation where asepsis may have been compromised must be changed
after 24 hours.
4.4
The cannulation site should be reviewed on each shift change and on
administration of IV drugs. This must be recorded on the Trust cannula care
record see page 20.
4.5
All cannulae should be changed every 72 hours, or as per manufacturers
recommendations, or sooner if complications are suspected. A suitable
dressing must be used to ensure secure fixation and allow observation of
site. Dressings should be changed if soiled on review.
4.6
Cannulation may only be carried out by a practitioner who has received
Cannulation insertion training and assessed as competent.
4.7
Where drugs have been added to bags, mini bags or syringes, an
intravenous additive label (available from Pharmacy) must be completed and
attached to the bag or syringe.
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4.8
After the addition of any drug to a bag, thorough mixing must be ensured.
This prevents layering of drug and ensures a constant dose is given.
4.9
The following information must be included on the additive label as well as
on the cannula care plan, see page 20.
•
•
•
•
•
patient’s name and Hospital number
drug name/dose/batch number/expiry date
date and time drug added
details of diluents
signature of administering practitioner and checker (where appropriate)
Use of Flushes to Maintain Patent Peripheral Lines
5.
Maintenance of the patency of peripheral intravascular catheters is important
to reduce the discomfort and expense of replacement.
5.1
The NPSA Rapid Response Report (April 2008) has identified a number of
incidents of harm or potential harm from heparin flushes. Therefore,
Practitioners are required to use 5ml sodium chloride 0.9% before and after
the administration of IV drugs in order to flush the cannula. This may be
administered against the patient group direction for 0.9% saline flush where
the practitioner has been assessed as competent to use this and signed for
on the prescription chart.
5.2
To maintain patency the method of flushing to be employed is the ‘push
pause’ technique and to end the flush with a positive pressure.
5.3
For central lines, specific flushing solution advice and guidance should be
sought from the pharmacy department and recorded in the medical notes
(refer to page 55).
Potency and Incompatibility of IV Drugs
6.
Drugs administered by the IV route have a more immediate and potentially
greater effect than those administered by other routes. There is also a risk
of incompatibility between drugs and intravenous solutions.
6.1
Potassium Chloride for injection must not be kept in stock due to the serious
consequences of accidental administration.
6.2
IV fluids with added potassium are available from pharmacy. Potassium
Chloride must never be administered by bolus dose and practitioners must
not add Potassium Chloride to infusion fluids.
6.3
When adding and mixing drugs the monographs must be checked to ensure
compatibility using the Monograph (page 22). Drugs must not be added to
the following:
•
•
blood, plasma and blood products
parental nutrition regimes
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•
•
Mannitol
Sodium bicarbonate
6.4
IV drugs must be administered or added to intravenous solutions
immediately following reconstitution. Delay may result in degradation and
loss of potency and microbial growth.
6.5
A 5ml Sodium Chloride 0.9% flush must be administered before and after
giving any drug.
6.6
For flushing a 10ml syringe must be used to reduce the pressure using a
push pause technique to minimise occlusion.
6.7
The registered practitioner who is to administer the drugs must prepare
them.
6.8
Drugs must not be pre-prepared for another practitioner to administer unless
that person is present or there are specific protocols agreed by the
Pharmacy and department staff
Education and Training - Basic Scope Package
7.
All practitioners who undertake intravenous medicines administration shall
undergo competency based training. This shall cover the following areas:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
7.1
Responsibilities of staff (e.g. nurse, doctors, and pharmacists)
Anatomy and Physiology of the circulatory system and veins of the
arms and hands.
Theory and practical session in intravenous cannulation.
Hazard involved in the preparation of injections
Calculations including a drug calculation test.
Drug incompatibilities
Stability of prepared injections
Displacement values
Aseptic technique
Checking procedures
Documentation
Labelling
Disposal of waste
Sources of information
Awareness of COSHH and other health and safety considerations
Care and management of vascular access devices
Infection control principles
Use of infusion equipment
Practical session in drawing up and administering IV medicines.
Complications of IV therapy.
Assessment of Competency
Successful completion of this package shall enable the person to prepare
and administer.
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February 2014
1.
2.
3.
4.
5.
6.
7.2
In addition to the Basic Scope package the training shall include
•
•
•
•
7.3
Ready to use IV medicines
IV bolus
IV infusions
Additions of a single medicine to an infusion bag
Administration via an IV infusion pump
Basic Scope plus Syringe Driver Competences now being delivered by
competency assessed staff within the Trust (refer to syringe driver
policy)
Type of devices
Specific hazards associated with syringe drivers
Hazards associated mixing medicines
Calculation in relation to syringe driver
Successful completion of this package shall enable the person to prepare
and administer drug additions to a syringe for administration by a driver
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Surname:
Forename:
Peripheral Cannula should be removed and
replaced at 72 hours
Date of Birth:
Always remove cannula as soon possible if no
longer needed
NHS No:
CANNULA ASSESSMENT TOOL
Score
0
1
2
Indications
Patient comfortable
Site appears healthy
Infusion runs/flushes
well
Slight pain, redness or
swelling and/or slight
resistance to infusion
Pain, redness or
swelling and/or inability
to flush
Action
Document site as satisfactory and continue observation
Consider saline flush (if compatible
Assess whether prescribed drugs or fluids may cause
damage
Document condition of site and observe more frequently
Be prepared to remove cannula
Remove cannula
Document condition of site and action taken
Re-inspect and report after removal of cannula
Involve pt/carer and doctor as appropriate
CANNULA 1
Insertion of Cannula
Cannula Record
Date and time of insertion
Site of cannula
Day Date Score
Device used:
1
Size:
2
Inserted by (print name):
3
Date and time of removal:
4
Mark with an ‘X’ position of each
cannula
Initials
am
pm
am
pm
am
pm
am
pm
CANNULA 2
Insertion of Cannula
Cannula Record
Date and Time of Insertion
Site of cannula
Day
Date Score
Device used
Initials
am
1
Size
2
Inserted by (print name)
3
Date and Time of Removal
4
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February 2014
Surname:
Forename:
Peripheral Cannula should be removed and
replaced at 72 hours
Date of Birth:
NHS No:
Always remove cannula as soon possible if no
longer needed
CANNULA ASSESSMENT TOOL
Score
Indications
Patient comfortable
Site appears healthy
0
Infusion runs/flushes
well
Slight pain, redness or
swelling and/or slight
1
resistance to infusion
2
Pain, redness or
swelling and/or inability
to flush
Action
Document site as satisfactory and continue observation
Consider saline flush (if compatible
Assess whether prescribed drugs or fluids may cause
damage
Document condition of site and observe more frequently
Be prepared to remove cannula
Remove cannula
Document condition of site and action taken
Re-inspect and report after removal of cannula
Involve pt/carer and doctor as appropriate
CANNULA 3
Insertion of Cannula
Cannula Record
Date and time of insertion
Site of cannula
Day Date Score
Device used:
1
Size:
2
Inserted by (print name):
3
Date and time of removal:
4
Mark with an ‘X’ position of each
cannula
Initials
am
pm
am
pm
am
pm
am
pm
CANNULA 4
Insertion of Cannula
Cannula Record
Date and Time of Insertion
Site of cannula
Day
Date Score
Device used
Initials
am
1
Size
2
Inserted by (print name)
3
Date and Time of Removal
4
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Guidance on how to access the Intravenous Drug Monograph
from the Taunton and Somerset NHS Foundation Trust Intranet for
Community Health Services
1.
Find available computer and log onto internet explorer. This is the homepage
for your intranet.
2.
At the bottom of the page under ‘Local NHS Links’ find and click on Taunton
and Somerset NHS Foundation Trust.
3.
Once you have clicked on the link you will then be presented with Taunton
and Somerset Trust’s homepage.
4.
At the top of the page click on “Divisions and Departments”. In the
Department search box you will see the A-Z, click on P, you will then see a
list of departments beginning with P, click on Pharmacy. This is now the
Pharmacy Homepage.
5.
On the left hand side of the page is a long narrow green box with subsections inside; left click on ‘Injectable Medicines’.
6.
You are now on the Injectable Medicines Administration Guide page. You
will also see the A-Z again, this time it represents the initial letter for the drug
you are giving, for example, Metoclopramide, click on M and look down the
list of drugs starting with M. When you see Metoclopramide left click on it
and this will reveal the Monograph for this drug.
7.
Once monograph found, print off and keep with the drug administration chart
for that patient for the duration of the treatment in accordance with the IV
Drug Administration Policy.
8.
Remove and destroy IV Monograph once the course of treatment is
complete.
Please familiarise yourself with this site and the principles of always
checking the monograph prior to administering the intravenous drug as the
monograph guidelines are live and can be changed or updated at any time
without any prior warning.
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APPENDIX B
PATHWAY FOR APPROVAL FOR ADMINISTRATION OF RED DRUGS
Request to administer Red Drugs
Escalate to Head of Division to ascertain if it safe to administer and staff have capacity to undertake
this role
Yes
No
Does it require specialist skills?
Yes
Head of Medicines
Management
*Clinical Management Plan
•
•
Is clinical management plan* in
place and agreed with Prescriber
and GP
No
Senior Nurse for the team to discuss
with Clinical Practice team and
confirm training and competency
requirements, competent to
administer
•
•
•
Yes
No
Senior Nurse for the team refers back to
referrer with explanation
•
Document request and
arrange for administering
nurse to have copy of
clinical management plan*
•
Senior Nurse for the team to talk to referrer
and arrange clinical management plan* to
be agreed with Prescriber and GP
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Head of Division
advised
February 2014
•
Referral letter
Confirmation that patient
consenting and agrees
to treatment plan
Somerset Partnership
Prescription sheet
completed by prescriber
and submitted
Contact details of
prescriber confirmed
Drug treatment protocol
supplied to include
possible side effects and
responding actions
required
Skills requirement
confirmed
Confirmation that GP
aware
Confirmation of drug
supply by prescriber or
by patient (FP10)
Start date agreed
APPENDIX C
INTRAMUSCULAR INJECTIONS INCLUDING DEPOTS
1.
The choice of injection site is crucial as the uptake of medication can be
enhanced or diminished depending on the site chosen (Nicoll and Hesby
2002).
1.1
Knowledge and use of appropriate sites reduce likelihood of injuries (Rodger
and King 2000) and can promote patient comfort.
1.2
There are 5 suitable sites for intramuscular injection (see pages 28, 29, 32),
it is vital that nurses are aware of the current evidence relating to the use of
all 5 sites in order to make an informed decision regarding administration
(Rodger and King 2000).
1)
Dorsogluteal (buttock)
2)
Ventrogluteal (hip)
3)
Deltoid (upper arm) – provides the most rapid absorption rate
4)
Vastus lateralis (thigh) – quicker absorption rate than buttock
5)
Rectus femoris (thigh)
1.3
The ventrogluteal site, see diagram 4, is recommended for the following
reasons:•
greatest thickness of gluteal muscle
•
free of penetrating nerves
•
free of major blood vessels
•
consistently thinner layer of fat over the muscle
1.4
The use of the Z-track method (see page 32) appears to be widely practised
(Rodger and King 2000). This technique creates a disjointed injection
pathway which:•
•
•
•
1.5
prevents seepage of medication
can prevent skin staining
diminishes subcutaneous irritation
enhances patient care by reducing pain and injection site lesions
(Beyea and Nicoll 1996)
A small test dose of injection must be given before the full treatment
schedule is initiated for oil based depots to minimise the adverse effects
(refer to product summary and BNF).
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Intramuscular needle gauge size and length
2.
It is essential to use the syringe and needle that is supplied with the
medication, if this is not available then it is important for needles to be long
enough to penetrate the muscle and still allowing a quarter of the needle
length to remain external to the skin. The most common size is 23 Gauge or
21 Gauge (2.5-5.0 cm long) for patients with more subcutaneous tissue.
2.1
It is important that when choosing the length of the needle that the muscle
mass of the injection site is assessed to ensure that the needle does not end
up in the subcutaneous tissue.
2.2
Where a product is provided in a pack with a syringe and needle for
administration this technology will have been through a rigorous evaluation
process in order for the company to gain a marketing authorisation (product
licence) for the their product. The syringe and needle provided should
ALWAYS be used. It is important to read the manufacturer’s instructions
regarding syringe and needle selection as packs and presentations may
vary.
Cytotoxic Therapy
3.1
For disconnection and disposal of cytotoxic infusion pumps, please refer to
Appendix E
3.2
In accordance with national guidelines, only a registered nurse or medical
practitioner, who has undergone further training, specifically in the
administration of cytotoxic intramuscular drugs, may administer treatments.
Proper Health and Safety risk assessments must be carried out prior to
administration, particularly with regard to waste disposal and spillage.
3.3
The practitioner administering cytotoxic injection treatments must have the
drug checked by a second practitioner. For cytotoxic treatment in the
community setting:
•
•
•
there must be a responsible clinician competent to prescribe cytotoxic
therapy managing the treatment
proper Health and Safety risk assessments must be carried out prior to
administration, particularly with regard to waste disposal, spillage and
extravasation
the disposal of any remaining cytotoxic drugs or equipment should be
in a purple lidded sharps bin as per the Trust Healthcare (Clinical)
Waste policy
Sciatic nerve injury
4.
Current research is unanimous in advocating the ventrogluteal site as
opposed to the dorsogluteal (Cocoman and Murray, 2008; Greenway et al,
2006; Small, 2004; Rodger and King, 2000).
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4.1
Small (2004) conducted a systematic review and Meta-analyses to identify
factors which can lead to sciatic nerve injury in adults and preventative
measures which can be taken by nurses. Small (2004) concluded that:•
the causative factors of sciatic nerve injury may be mechanical or
chemical
•
even if the needle does not penetrate the nerve, the medication or
sheer volume could affect the nerve
4.2
Possible complications from sciatic nerve injury are:•
excruciating burning pain unrelieved by analgesia
•
motor loss e.g. foot drop, loss of toe flexion and extension
•
sensory loss e.g. protective foot sensation
•
complete paralysis
4.3
A retrospective study of 380 sciatic nerve injuries over 24 years at a
University medical centre discovered 33% of cases were directly associated
with intramuscular injection (Kline et al 1998).
4.4
The strength of Small’s (2004) review is the inclusion of court cases from
Canada and USA implicating sciatic nerve injury in association with
intramuscular injection. Of 16 court cases identified:•
•
•
4.5
6 decisions were found in favour of the plaintiff
1 case was agreed by out of court settlement
remaining 9 cases failed due to lack of proof or legal problems
Small (2004) emphasises the importance of accurate documentation.
•
in 5 court cases the site of injection was identified as the buttock or
quadrant method, resulting in claims against staff
•
alternatively, in another case, a nurse documented that the injection
was given in the hip and although the patient stated it was in the
buttock, they were not found guilty of negligence.
Advantages and disadvantages of intramuscular injections (with
special reference to long acting antipsychotic depot injections)
4.6
Advantages may include;
•
•
•
•
•
•
reduces necessity for tablets or capsules to be taken on a daily basis
reduces uncertainty about the amount of medicine taken or not taken
no influence of first-pass metabolism thus improved bioavailability
more consistent delivery of antipsychotic medications with more stable
plasma levels over time which can minimise side-effects and reduce
variations in symptom control
earlier detection of non-adherence which can be followed up quickly
resulting in a potentially reduced relapse rate leading to better outcomes
possibly a reduced risk of admission with potential resultant cost savings
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February 2014
•
•
•
4.7
potentially reduced need for repeat prescriptions since the dosing interval
of such formulations is normally between one and four weeks
reduces the risk of accidental or deliberate self harm through overdose
the potential to enhance the therapeutic relationship and partnership
working with the patient and their carer (if appropriate) by the regular
frequent contact required
Disadvantages may include;
•
•
•
•
•
•
•
•
•
pain, erythema, swelling at the site of injection as well as nodule
formation particularly with oil-based injections
risk of damage to nerves, arteries or veins
if side-effects occur they will be prolonged until plasma levels fall, hence
the necessity of a test dose of the oil-based depot formulations
the need to confirm efficacy and tolerability to the oral formulations of the
non-oil based long-acting injections where required and practical
it can take several weeks for plasma levels to reach steady state
some people have a dislike or even have a phobia of needles
social embarrassment and the need for chaperoning and gender
matching in Mental Health Services
staffing and medicine storage requirements
in the past depot injections in mental health services have been viewed
by some as stigmatising and coercive
Ethical Perspectives
5.
Nurses have a legal and ethical duty to deliver evidence-based care (NMC
2008). However, researchers have been surprised to discover that the
dorsogluteal site is still commonly used in practice in preference to the
ventrogluteal site (Cocoman and Murray, 2008; Greenway et al, 2006; Small,
2004).
5.1
The moral obligation of non-maleficence requires nurses to respect others
and take due care not to harm patients (Henry 1996).
5.2
In addition, justice relates to the moral principle of care whereby an
organisation should have policies in place to support the welfare of patients
and staff (Henry 1996).
5.3
For some cultures it is unacceptable to expose the gluteal region, therefore
patients may prefer the deltoid site (Pandian et al 2006).
5.4
Prevailing obesity is another dimension to be considered with the gluteal
muscles beyond the reach of standard needles in the majority of obese
patients (Zaybak et al 2007).
5.5
This raises legal and ethical issues regarding the licensing agreement of
medications which are licensed for intramuscular use and are in fact given
subcutaneously (Greenway et al 2006).
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REFERENCES
Beyea, S.C; and Nicoll, L.H. (1995) Administration of Medications via the
Intramuscular Route: An Integrative Review of the Literature and ResearchBased Protocol for the Procedure, Applied Nursing Research, 8(1): 23-33.
Beyea, S.C; and Nicoll, L.H. (1996) Administering IM Injections the Right
Way: Back to Basics, American Journal of Nursing, 96 (1): 34-35.
British National Formulary, March 2012, no. 63. BMJ Group and RPS
Publishing.
Campbell, J. (1995) Injections, Professional Nurse, 10(7): 455-458.
Chiodini, J. (2000) Vaccine Administration, Nursing Standard, 14(43): 39-42.
Cocoman, A; and Murray, J. (2008) Intramuscular Injections: A Review of
Best Practice for Mental Health Nurses, Journal of Psychiatric and Mental
Health Nursing, 15: 424-434.
Diggle, L. (2007) Injection Technique for Immunisation, Practice Nurse,
33(1): 34-37.
Feetam C. & White J. Eds. (2011) Guidance on the Administration to Adults
of Oilbased Depot and other Long-Acting Intramuscular Antipsychotic
Injections 3rd Edition. Available at www.hull.ac.uk/injectionguide accessed
15th September 2011. Commissioned by Janseen.
Mallet, J. and Dougherty, L. 2011. Royal Marsden Hospital Manual of
Clinical Nursing Procedures. 8th ed. Blackwell Science
Greenway, K. (2004) Using the Ventrogluteal Site for Intramuscular Injection,
Nursing Standard, 18(25): 39-42.
Greenway, K; Merriman, C; and Statham, D. (2006) Using the Ventrogluteal
Site for Intramuscular Injections, Learning Disability Practice, 9(8): 34-37.
Henry, C. (1996) Principles and Values: An Ethical Perspective in Healthcare
Organizations, in Soothill, K; Henry, C; and Kendrick, K. (eds.) Themes and
Perspectives in Nursing. 2nd ed. London: Chapman & Hall.
Higgins, D. (2004) IM Injection, Nursing Times, 100(45): 36-37.
Hunter, J. (2008) Intramuscular Injection Techniques, Nursing Standard, 22
(24): 35-40.
Kline, D.G; Kim, D.M; Midha, R; Harsh, C; and Tiel, R. (1998) Management
and Results of Sciatic Nerve Injuries: A 24-Year Experience, Journal of
Neurosurgery, 89: 13-23.
Nicoll, L.H. and Hesby, A. (2002) Intramuscular Injection: An Integrative
Research Review and Guideline for Evidence-Based Practice, Applied
Nursing Research, 16(2): 149-162.
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Nursing and Midwifery Council (2008) The Code: Standards of Conduct,
Performance and Ethics for Nurses and Midwives. London: NMC.
Pandian, J.D; Bose, S; Daniel, V; Singh, Y; and Abraham, A.P. (2006) Nerve
Injuries Following Intramuscular Injections: A Clinical and Neurophysiological
Study from Northwest India, Journal of the Peripheral Nervous System, 11:
165-171.
Patel MX. Taylor M. David AS. Eds. Antipsychotic long-acting (depot)
injections for the treatment of schizophrenia. (2009). British Journal of
Psychiatry, 195(52): (Suppl) 1-67.
Promoting Safer Use of Injectable Medicines. Patient Safety Alert (2007),
National Patient Safety Agency London, UK. (Accessed 23/09/08):
www.npsa.nhs.uk/patientsafety/alerts-and-directives/alerts/injectablemedicines/
Rodger, M.A. and King, L. (2000) Drawing up and Administering
Intramuscular Injections: A Review of the Literature, Journal of Advanced
Nursing, 31(3): 574-582.
Small, S.P. (2004) Integrative Literature Reviews and Meta-Analyses:
Preventing Sciatic Nerve Injury From Intramuscular Injections: Literature
Review, Journal of Advanced Nursing, 47(3): 287-296.
Workman, B. (1999) Safe Injection Techniques, Nursing Standard, 13(39):
47-53.
World Health Organisation [online] (2006) ‘Injection Safety.’
http://www.who.int/mediacentre/factsheets/fs231/en/print.html, (1 March
2009).
Wynaden, D; Landsborough, I; and Chapman, R. (2005) Establishing Best
Practice Guidelines for Administration of Intramuscular Injections in the
Adult: A Systematic Review of the Literature, Contemporary Nurse: A
Journal for the Australian Nursing Profession, 20(2): 267-277.
Zaybak, A; Güneş, Ü; Tamsel, S; Khorshid, L; and Eşer, İ. (2007) Does
Obesity Prevent the Needle from Reaching Muscle in Intramuscular
Injections? Journal of Advanced Nursing, 58(6): 552-556.
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INTRAMUSCULAR INJECTION SITES (refer to manufacturers instructions)
1) LOCATION OF THE DELTOID SITE (not recommended for depot injections
apart from Risperidone long acting, unless specified by prescriber)
Recommended for Hepatitis B vaccination
The densest part of the muscle can be found by identifying the acromial process and
the point on the lateral arm in line with the axilla.
Asking patients to put their hand on their hip like a fashion model relaxes the muscle
and makes it easier to access. The needle should be sited about 2.5cm below the
acromial process at 90°. The radial nerve and the brachial artery must be avoided
(Workman 1999). Only small amounts (2ml volume) should be administered to this
site.
2) LOCATION OF THE VASTUS LATERALIS & RECTUS FEMORIS SITES (not
recommended for depot injections unless specified by prescriber)
In an adult the vastus lateralis can be located by measuring a hand's breadth
laterally down from the greater trochanter, and a hand's breadth up from the knee,
Administration by Injection Policy
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identifying the middle third of the quadriceps muscle as the injection site. The rectus
femoris is in the middle third of the anterior thigh (Workman 1999).
3) LOCATION OF THE DORSOGLUTEAL SITE (recommended site for depot
injections, in particular Depoprovera)
Draw an imaginary horizontal line across from the top of the cleft in the buttocks to
the greater trochanter of the femur. Then draw another line vertically midway along
the first line, and the location is 'the upper outer quadrant of the upper outer
quadrant' (Campbell 1995).
That muscle is the gluteus maximus (Workman 1999).
4) LOCATION OF THE VENTROGLUTEAL SITE (recommended site for depot
injections, including Depoprovera for obese women)
Place the palm of your right hand on the greater trochanter of the patient’s left hip or
your left hand to patient’s right hip (Workman 1999).
Extend your index finger to touch the anterior superior iliac crest and stretch the
middle finger to form a V as far as possible along the iliac crest as you can reach
(Beyea and Nicholl 1995).
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Clinical guidelines for administering intramuscular injections in adults
1.
Check prescription for drug, time, dosage and route of administration with
another nurse
2.
Use 21 or 23 gauge for drawing up medication
3.
Change needles after drawing up
4.
Choose a needle of appropriate length to ensure medication is deposited in
the muscle bed
5.
Do not use the air bubble technique
6.
Use the ventrogluteal as the site of choice unless contra-indicated
7.
Assist patient into correct position to access site
8.
Apply gloves and personal protective equipment if required
9.
Swab the site with an alcohol pre-injection wipe
10.
Use the Z-track method for all injections
11.
Quickly plunge the needle into the skin at 90 degree angle leaving one third
of the shaft of the needle exposed
12.
Aspirate for blood – if present, discard and prepare new injection
13.
Inject medication at a rate of 1mL per 10 seconds
14.
After 10 seconds withdraw the needle rapidly – apply pressure to any
bleeding point
15.
Do not massage the site
16.
Dispose of sharps safely and document procedure
17.
Observe the site 2-4 hours after injection (inpatient areas) or 10-15 minutes
(community setting) to identify and monitor any side effects (Rodger and
King 2000)
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Checklist for Preparation of Intramuscular (IM) Injections
Process 1
Check to see if the patient’s physical or mental health has changed since the
previous contact, including the health of the injection sites.
Process 2
Ask about perceived benefit and any side-effects experienced since the last
injection, if this is not the first.
Process 3
Check to ensure:
• The prescription is legal and valid
• The dose is due
• The dose has not already been given
• There are no contra-indications or allergies
• The injection is “in date”
Process 4
Confirm that the patient has the capacity to consent and gives their consent to the
procedure.
Process 5
Wash your hands according to accepted hand cleansing technique and apply
disposable gloves.
Process 6
Prepare the injection making any necessary dose calculation and using the correct
equipment.
Process 7
Get a second registered practitioner, if available, to double check all items in
processes 3, 4 & 6.
Process 8
If a second registered practitioner is not available, ask the patient to check that the
correct injection and dose is to be administered and that the injection is “in date”.
Process 9
Choose the site of administration according to the licensed indication for the injection
and in collaboration with the patient, proceed according to appendices 4-7.
Administration by Injection Policy
V5
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February 2014
COMPARISONS OF DORSOGLUTEAL & VENTROGLUTEAL SITES
(Greenway 2004)
Dorsogluteal
Ventrogluteal
Location: Upper outer quadrant of Location: Ball of opposing hand on
buttock. Visually bisect the buttocks greater trochanter and index finger
to locate site.
on the anterior superior iliac crest.
Form a ‘V’ with middle finger – site is
within the ‘V’.
Target muscle: Gluteus maximus
Target muscle: Gluteus medius
Advantages:
Advantages:
• Familiarity with procedure
•
•
Free from major blood vessels
& nerves
Consistent thinness of
subcutaneous tissue over
injection site. Disadvantages:
Disadvantages:
•
If the injection is administered inferior
or medially from the intended ‘upper
outer quadrant’ this may result in:
New practice – nurses’
unfamiliarity & lack of
confidence
•
Damage to the sciatic nerve,
leading to pain or paralysis
(temporary or permanent)
• Inadvertent administration of
the drug intravenously by
injecting into superior gluteal
artery
• Varying amounts of
subcutaneous tissue may
result in injection not reaching
muscle – causing irritation &
disrupting uptake of drug
• Dorsogluteal site is also
associated with tissue
necrosis, gangrene, pain,
muscle contraction and
fibrosis
Contraindications:
As above plus inflamed skin,
abscess, administration of hepatitis B
vaccine
Administration by Injection Policy
V5
Contraindications:
Inflamed skin, abscess, muscle
contraction, administration of
hepatitis B vaccine
- 35 -
February 2014
5. Z-TRACK TECHNIQUE (BEYEA & NICOLL 1996)
This has the advantage of achieving the correct plasma concentration whilst
minimising the risk of pain or lesions at the injection site.
•
•
•
•
•
Stretch the skin and subcutaneous tissue 2-3 cm using non-dominant hand
Pierce the skin at 90° with a quick dart-like motion
Aspirate for blood, and then if none,
Slowly inject the medication at a rate of 1ml per 10 seconds.
Withdraw the needle and release the tissue thereby locking in the
medication.
(Rodger and King 2000)
Maximum volume for oil-based depot administration into a single site
Administration by Injection Policy
V5
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February 2014
Generic Name
Brand/Trade name
Max Volume
Flupentixol decanoate
20mg in 1ml
Depixol Injection
2ml
Flupentixol decanoate
100mg in 1ml
Depixol Concentrate
2ml
Flupentixol decanoate
200mg in 1ml
Depixol Low Volume Injection
2ml
Fluphenazine decanoate
25mg in 1ml
Modecate Injection
Not specified in the
SmPC
Fluphenazine decanoate
100mg in 1ml
Modecate Concentrate Injection
Not specified in the
SmPC
Haloperidol decanoate
50mg in 1ml
Haldol Decanoate 50mg in 1ml
3ml
Haloperidol decanoate
100mg in 1ml
Haldol Decanoate100mg in 1ml
3ml
Pipotiazine palmitate
50mg in 1ml
Piportil Depot 5% w/v
Not specified in the
SmPC
Zuclopenthixol acetate
50mg in ml
Clopixol Acuphase
3ml
Zuclopenthixol decanoate
200mg in 1ml
Clopixol Injection
2ml
Zuclopenthixol decanoate
500mg in 1ml
Clopixol Concentrate Injection
2ml
SmPC – Summary of Product Characteristics
The product licences of individual antipsychotic injections indicate which sites are
permitted. Currently none of the depot or other long acting antipsychotic injections is
licensed for administration at the rectus femoris site.
Administration by Injection Policy
V5
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February 2014
APPENDIX D
CENTRAL LINE MANAGEMENT
1.
GUIDANCE
1.1
The following guidance on PICC and Hickman Line procedures are for
general guidance only. Staff managing patients with PICC or Hickman Lines
must ensure they follow the patient’s own specific care plan compiled by
their specialist Nurse or Consultant. If a care plan is not available then the
hospital specific guidelines detailed on page 66 of this document should be
followed.
Dressing and cleaning the insertion site of PICC lines
1.2
Assess the dressing in the first 24 - 48 hours after insertion, for accumulation
of blood, fluid or moisture beneath the dressing.
•
to prevent infection of the catheter, PICC line insertion sites needs redressing every 7 days, or as required if dressing becomes loose,
damp, soiled/blood stained
during all dressing changes, assess the external length of the catheter
to determine if any migration/withdrawal of the catheter has occurred
please refer to the patients specific care plan or page 55 for hospital
specific management guidelines for PICC lines
equipment required:
sterile Dressing pack
sterile Nitrile examination gloves
Steri - strips (12mm x 100mm) x 5
Permeable sterile transparent dressing – IV3000
cleaning agent 2% Chlorhexadine in 70% Isopropyl alcohol –
Chloraprep
non- sterile gloves for removal of old dressing
Statlock device (if required)
•
•
•
Procedure
Action
No
Procedure
Rationale
1
Explain procedure to the patient
Ensure patient
understands and required
to obtain informed consent
2
Wash hands thoroughly as per local policy
To reduce risk of infection
3
Open sterile dressing pack and prepare
dressing and cleaning equipment
Te reduce risk of infection
Administration by Injection Policy
V5
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February 2014
Action
No
Procedure
Rationale
4
Place sterile dressing towel under patient’s
arm
To reduce risk of infection
5
Carefully remove old dressing and Steri
Strips using a “from the bottom up”
technique, whilst avoiding tugging or
moving the catheter and avoid using
scissors or other sharp instruments near
the arm
Reduce risk of dislodging
the catheter and maintain
its integrity
6
If there is a statlock device in situ replace
the statlock device weekly. If it is causing
irritation or discomfort on removal discuss
this with the patient’s referring hospital
Ensures extra stability of
the external catheter to
prevent migration and less
frequent device changes
reduce risk of impaired
skin integrity
7
Inspect the catheter exit site for signs of
infection – swelling, redness, or oozing.
Notify GP or senior nurse if signs of
infection are evident
To ensure infection is
recognised and treated
promptly
8
Wash hands thoroughly and put on sterile
Nitrile examination gloves
Te reduce risk of infection
9
Clean the catheter exit site with 2%
Chlorhexadine solution in circular
movements moving away each time from
the exit site until at least 5cms in diameter
has been reached. Repeat twice and allow
the skin to dry for 30 seconds
To minimise risk of
infection spread from a
‘dirty’ to a ‘clean’ area. To
complete the
decontamination process
NB: the initial gauze dressing should be
removed after 48 hours following insertion
and not replaced unless excess oozing is
observed
10
Apply new Steri strips - 2 horizontally and 2
vertically to hold catheter firmly in place
and a new statlock device if required
To ensure patient comfort
and secure positioning of
the PICC line
11
Apply new sterile dressing – IV3000- using
aseptic technique, ensuring the catheter
exit site is in the middle of the dressing and
the port is left uncovered for easy access
To keep the line free from
infection and secure
12
Tubifast Tubigauze may be applied over
To aid patient comfort and
Administration by Injection Policy
V5
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February 2014
Action
No
13
Procedure
Rationale
the PICC to aid comfort and security
PICC line security
Document external line length in cm, site
observations, cleansing and dressing
change in patients evaluation record and
care plan
To ensure good
communication,
documentation and
continuity of care
Flushing the PICC line
2.
The Groshong PICC, in line with other Groshong catheters does not have a
clamp, but has a three-position, pressure-sensitive Groshong valve at the
internal tip of the catheter. The Groshong PICC line needs to be flushed
once weekly with at least 10mls 0.9% Sodium Chloride to maintain
patency. Ensure an asceptic technique is used
•
please follow patients’ specific care plans or refer to page 55 for
hospital specific management guidelines for flushing PICC lines
•
equipment needed:
sterile dressing pack
sterile Nitrile examination gloves
cleaning agent 2% Chlorhexadine in 70% Isopropyl alcohol wipes
minimum size 10 ml syringe
10mls of 0.9% Sodium Chloride
21G needle (green)
new sterile needless injection port if being used
Procedure
Action
No
PROCEDURE
RATIONALE
1
Explain procedure to patient
Ensure patient understands
obtain informed consent
2
Wash hands and prepare sterile
equipment
To reduce risk of infection
3
Place sterile dressing towel under the
patient’s arm
To reduce risk of infection
4
Draw up 10 mls 0.9% Sodium Chloride
into 10 - 20ml syringe using a green
needle
To reduce risk of infection
Administration by Injection Policy
V5
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February 2014
Action
No
PROCEDURE
RATIONALE
5
Remove needle from syringe
To establish connection
between cap an syringe
6
Put on sterile Nitrile gloves and clean the
needle free injection port with 2%
Chlorhexadine swab and allow to dry for
30 seconds
To reduce risk of infection
7
Connect syringe to the needle free
injection port using a firm twisting motion
and flush using a ‘push, pause’ technique.
On the final push, maintain positive
pressure as the syringe is withdrawn from
the cap
To create turbulence in
order to flush the catheter
thoroughly
NB: some needle free injection ports
already have an integral positive pressure
mechanism e.g. BD Posiflow, CLC 2000
8
Please follow the patient’s specific care
plan or hospital specific guidance on page
55 for frequency of changing needle free
injection port.
To reduce risk of infection
Using a sterile non-touch aseptic
technique, remove the needle free
injection port, clean the external part of
the catheter hub with a sterile 2%
chlorhexadine cleansing swab and allow
to dry for 30 seconds. Attach new sterile
needle free injection port and document
9
3.
Dispose of sharps and clinical waste as
per local policy
To reduce risk of infection
and adhere to Healthcare
(Clinical) Waste Policy and
Infection Control policy
Blood sampling from PICC line
Ensure the patient’s own specific care plan is followed or refer to
page 55 for hospital specific management guidelines for PICC line
if a care plan is not available.
•
equipment:
sterile dressing pack
sterile Nitrile examination gloves
1 x 20 ml luer lock syringe
Administration by Injection Policy
V5
- 41 -
February 2014
1 x 21G (green) needle
20mls 0.9% Sodium Chloride
cleaning agent 2% Chlorhexadine in 70% Isopropyl Alcohol
Vacutainer system and blood specimen tubes
1 x 6ml (yellow) Vactuainer sampling tube for discarding
new sterile needle free injection port if required
Procedure
Action
No
PROCEDURE
RATIONALE
1
Explain procedure to patient
Ensure patient
understands and obtain
informed consent
2
Wash hands and prepare sterile equipment
To reduce risk of
infection
3
Place sterile dressing towel under the
patient’s arm
To reduce risk of
infection
4
Draw up 20mls 0.9% Sodium Chloride into
20ml syringe using the green needle
To confirm line patency
5
If pre flush is required, clean the needle
free injection port and allow to dry.
Connect the 5ml flush onto the catheter
hub and follow flushing technique above.
Ensure line patency and
position
Ensure removal of any
saline solution or heparin
or other intravenous
Connect a compatible Vacutainer
medications from the
system/bottle holder onto catheter hub with
a firm twisting motion. Attach a 6ml sampling dead space that may
result in obscured blood
bottle (yellow) and allow to fill. Remove the
results
bottle and discard.
NB: samples required for blood cultures do
not require the disposal of this sample as
line contents are required for analysis.
6
Using the correct order of draw, attach the
Ensuring blood sample
required Vacutainer bottles and withdraw the follows correct
required samples
procedures and
guidelines
8
Remove the Vacutainer system, clean the
port with a new sterile 2% Chlorhexadine
cleansing swab
Administration by Injection Policy
V5
- 42 -
To reduce risk of
infection
February 2014
Action
No
4.
PROCEDURE
RATIONALE
9
Following blood sampling, the PICC line
MUST BE FLUSHED with 20mls 0.9%
Sodium Chloride in 20 ml syringe, using the
‘push, pause’ method
To create turbulence and
ensure removal of all
blood in the catheter and
prevent occlusion
10
Replace with a new sterile needless
injection port unless otherwise stated in
patients own care plan or hospital specific
guidelines at page 55
To prevent infection
Drug / fluid administration
An aseptic non-touch technique is required for administration of fluid
and/or medications
•
equipment:
sterile dressing pack
sterile Nitrile examination gloves
1 x 10ml leur lock sterile syringe
2 x 10-20 ml luer lock sterile syringe
2 x 10ml 0.9% Sodium Chloride for pre and post flushing
extra flushes and syringes for in between flushing after each medication
being administered.
21G green needles for drawing up flushes and medication
Taunton and Somerset NHS Foundation Trust (T+S) drug monographs for
each medication being administered intravenously (IV)
2 x 2% Chlorhexadine in 70% Isopropyl Alcohol cleansing wipes
sterile needless injection port if required.
Procedure
Action
No
Procedure
Rationale
1
Explain procedure to patient
Ensure patient
understands and required
to obtain informed
consent
2
Wash hands and prepare sterile equipment To reduce risk of infection
and IV medications / fluids using T+S drug and to prepare and
administer each
monograph
IV medication as per
policy
Administration by Injection Policy
V5
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February 2014
Action
No
Procedure
Rationale
3
Draw up 2 x 10mls 0.9% Sodium Chloride
into a 10-20ml syringe using a green
needle
To reduce risk of infection
4
Place a sterile dressing towel under the
patient’s arm
To reduce risk of infection
5
Clean the needle free port with 2%
Chlorhexadine and allow to dry. Connect
an empty 10ml syringe onto catheter hub
with a firm twisting motion, pull back
slowly, pausing to allow catheter valve to
open and blood to withdraw into the
catheter. Continue to aspirate until at least
1-2mls of blood is obtained
Ensure patency of the
catheter and correct
placement
6
Remove the syringe and discard
To prevent risk of
contamination
7
Cleanse the needle free injection port
again with a second sterile 2%
Chlorhexadine wipe
To prevent risk of
infection
8
Connect the syringe using a firm twisting
motion to the needle free injection port and
flush the catheter line with at least 10mls
0.9% Sodium Chloride using push/pause
technique. Maintain positive pressure as
the syringe is removed from the hub
To create turbulence in
order to flush the catheter
thoroughly
9
Attach the bolus prepared IV medication or Administration of IV
medications are per policy
infusion onto the port, and administer at a
rate directed by the Taunton and Somerset
NHS Foundation Trust (T+S) drug
monograph. Flush the line in between each
IV medication being administered with
10mls of a compatible solution
10
On completion, a second flush of the line is
required using the same method as
described in point 8
To create turbulence and
ensure removal of all
medications in the
catheter and prevent
occlusion
11
Document the procedure and any
observations in the MAR and nursing
As per Medicines Policy
Administration by Injection Policy
V5
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February 2014
Action
No
Procedure
Rationale
evaluation notes
5. Removal of Central Venous Access Devices (PICC Lines Only)
PICC Lines MAY NOT be removed until instructed by the medical team
in charge of patient care.
An aseptic non-touch technique is required for removal of PICC line.
Equipment;
•
Sterile dressing pack
•
Sterile gloves
•
Plastic apron
•
Non- sterile gloves
•
Sterile gauze occlusive transparent dressing
•
Chlorhexidine gluconate 2% sterile aqueous solution
Action
No
1
2
3
4
Procedure
Rationale
Explain the procedure to the patient
Lie patient flat and place arm at 90o
angle to ease removal
Wash hands thoroughly following
infection control policy and prepare
sterile equipment
Using non – sterile gloves remove
existing dressing and STAT lock
Open sterile dressing pack and put
on sterile gloves
To ensure the patient
understands the procedure
and gives valid consent
To prevent the risk of air
embolism
To minimise the risk of
infection
To prepare for catheter
removal
Place sterile towel under PICC line
5
6
Clean catheter exit site with
Chlorhexidine Gluconate 2% sterile
solution, starting at exit site and
spiralling outwards until 5cms
diameter has been cleaned,
Repeat twice and allow to dry for 30
seconds
Advice the patient to breathe in,
hold their breath then exhale,
Whilst exhaling gently and slowly
pull back on the catheter until it is
Administration by Injection Policy
V5
- 45 -
To prevent contamination of
the site
To remove the catheter and
prevent damage to vein
February 2014
7
8
9
10
11
12
13
completely removed from the exit
site
Apply pressure to the exit site for
approximately 2-4 minutes with
sterile gauze until haemostasis is
achieved
Stop if any resistance is felt and
seek specialist advice
Apply clean sterile gauze and an
occlusive dressing and keep in
place for 48 hours
Examine tip of PICC line to ensure
complete (straight clean horizontal
cut and the length removed the
same that was documented at
insertion).
There should be no ragged edges.
If this is observed inform medical
staff immediately, contact the
centre where the PICC was
inserted and retain the PICC for
inspection.
Catheter tip will only need to be
sent to Microbiology if infection is
queried, please send for M, C and
S (microscopy, culture and
sensitivity.
Using sterile scissors cut off
approx. 5 cm from the tip and place
in a sterile pot
Dispose of all clinical waste as per
policy
Ensure all details for removal are
documented:
Name of medical practitioner
making decision for removal
Reason for removal
Any problems identified during
removal
Condition of insertion site
(inflammation, bruising, pain,
bleeding etc.)
If infection is suspected, date and
time tip sent to microbiology.
To minimise blood loss and
bruising
To prevent breakage of line or
damage to the patient’s vein
To provide protection to entry
site
To ensure complete catheter
has been removed
that catheter length of catheter
is the same as at insertion
To detect any infection related
to the catheter and thus
provide necessary treatment.
(As per policy for MPH, RUH
and YDH)
To ensure safe disposal in the
correct containers and avoid
laceration or injury of other
staff.
To ensure records are kept up
to date
Continued care of the patient
(Marsden 2011 and Royal United Hospitals Bath – Care of Central Venous
Access Devices 2007)
6.
Hickman Lines
Dressing and cleaning the insertion site
Administration by Injection Policy
V5
- 46 -
February 2014
6.1
Always using an aseptic technique, the dressing must be changed 24 hours
after insertion and weekly thereafter, or when the dressing becomes damp,
loose or soiled.
•
entry site Steri-strips must be removed after 7 days post insertion and
sutures removed 21 days post insertion, or until the cuff fibroses and
the surrounding catheter tissue secures the catheter in place
ideally, the sutures should be removed within a hospital environment by
experienced and competent nursing staff and where medical attention
is immediately available, should the integrity of the catheter be
compromised
Hickman lines can be open ended or valved and have up to three
lumens. Groshong catheters are valved
open ended catheters have a clamp on each lumen which must remain
closed/clamped at all times when not in use
immediately after suture removal, each lumen must be flushed with
heparinised saline solution 50iu/5mls to ensure catheter patency
the patency of each lumen will be maintained by flushing with 10 or
20mls 0.9% Sodium Chloride and 5mls heparinised saline 50ui/5mls
during all dressing changes, the external length of the catheter must be
assessed and measured to determine if migration of the catheter has
occurred and to ensure the Dacron cuff is not visible
•
•
•
•
•
•
•
equipment:
sterile dressing pack
sterile Nitrile examination gloves
transparent semi-permeable film dressing – IV3000
non sterile gloves for removal of old dressing
2% Chlorhexadine in 70% Isopropyl Alcohol cleansing solution – Chloraprep
Procedure
Action
No
Procedure
Rationale
1
Explain procedure to the patient
Ensure patient
understands and obtain
informed consent
2
Wash hands thoroughly as per local policy
To reduce risk of infection
3
Open sterile dressing pack and prepare
dressings and cleaning equipment.
To reduce risk of infection
4
Place sterile dressing towel under exit site
To reduce risk of infection
5
Carefully remove the old dressing using a
“from the bottom up” technique, whilst
avoiding tugging or moving the catheter
Reduce risk of dislodging
the catheter and maintain
Administration by Injection Policy
V5
- 47 -
February 2014
and avoid using scissors or other sharp
instruments near the area
its integrity
6
Inspect the catheter exit site for signs of
infection – swelling, redness, or oozing.
Notify GP or senior nurse if signs of
infection are evident
To ensure infection is
recognised and treated
promptly
7
Wash hands thoroughly and put on sterile
Nitrile examination gloves
To reduce risk of infection
8
Clean the catheter exit site with 2%
Chlorhexadine in circular movements
moving away each time from the exit site
until at least 5cms in diameter has been
reached including the part of the catheter
that is under the dressing. Repeat twice
and allow the skin to dry for 30 seconds
To minimise risk of
infection spread from a
‘dirty’ to a ‘clean’ area. To
complete the
decontamination process
9
Apply new sterile dressing – IV3000- using
an aseptic technique, over the whole site.
Loop the catheter if required but avoid
kinking
To minimise risk of
infection and provide
security of the line
10
Document external line length in cm, site
observations, cleansing and dressing
change in the patients evaluation record
care plan (page 67)
To ensure good
communication,
documentation and
continuity of care
Flushing Procedure
6.2
The Groshong skin-tunnelled catheter does not have a clamp but has a
three-position, pressure sensitive valve at the tip of the catheter.
•
•
The Groshong lines and open ended lines need to be flushed when not
in regular use. Groshong lines are flushed with at least 10mls 0.9%
sodium chloride depending on patients specific care plan and hospital
specific guidelines, (see page 67) to maintain patency. Open ended
lines may require an appropriate heparin solution to maintain line
patency depending on patients specific care plan and hospital specific
guidelines (see page 67)
after all catheter use or if blood is observed in the catheter, it should be
irrigated with at least 10mls 0.9% sodium chloride to prevent occlusion
positive pressure needleless connectors are usually used for open
ended catheters. Where standard Bionector is in place it is very
important to end flush using positive pressure technique to prevent
clotting in the line
an aseptic non- touch technique is used
•
equipment:
•
•
Administration by Injection Policy
V5
- 48 -
February 2014
sterile Nitrile examination gloves
2 x 2% Chlorhexadine in 70% Isopropyl Alcohol cleansing wipes
10ml or 20 ml syringe
10-20mls 0.9% Sodium Chloride
5mls Heparinised saline if required
recommended needless injection port if required
sterile dressing pack
Procedure
Action
No
Procedure
Explain procedure to patient
1
2
3
4
5
Rationale
Ensure patient
understands and obtain
informed consent
Prepare equipment and wash hands
To reduce risk of infection
Draw up the appropriate recommended
flush or flushes (may require heparinised
saline) as per patients care plan or
hospital specific guidelines (page 55)
To ensure adequate
flushing within the catheter
line
Place sterile dressing towel under line
Put on sterile gloves
To reduce risk of infection
To prevent cross infection
6
Clean needle free injection port thoroughly
with Chlorhexidine/ alcohol wipe. Allow
port to dry for 30 seconds
7
Connect syringe directly onto needle free
injection port using a firm twisting motion
8
Flush with push -pause action and use
positive pressure technique when
removing syringe after flush complete
9
Change needless injection port as
recommended by the patients care plan or
hospital specific guidelines (page 55)
To reduce risk of infection
Te reduce risk of infection
and ensure safety of
procedure
To ensure adequate
turbulence is created within
the catheter
To minimise risk of
infection and provide
security of the line
Remove the needle free injection port
Clean catheter hub with a new 2 %
Chlorhexidine wipe
Allow to dry
Administration by Injection Policy
V5
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February 2014
Action
No
Procedure
Rationale
Apply new needle free injection port
10
Dispose of equipment safely
As per Healthcare
(Clinical) Waste policy
Blood Sampling
6.3
The red lumen is larger than the white so should be used for blood sampling
if possible.
•
•
•
drugs requiring ‘levels’ should be given down the white lumen, so that
blood can be taken from the red lumen. Using the same lumen for
giving the drug and taking blood levels can lead to misleading results
all infusions (both lumens) via the catheter should be stopped before
taking blood, otherwise results may be unreliable. A suitable period of
time should be allowed between stopping infusions and withdrawal of
blood samples to prevent erroneous results
if blood sampling is difficult it may help to lie the patient down as this
will encourage venous filling and reduce the possibility of damage to
the vessel wall due to suction
Administration by Injection Policy
V5
- 50 -
February 2014
Procedure
Action
No
PROCEDURE
RATIONALE
1
Explain procedure to patient
Ensure patient understands
and obtain informed consent
2
Wash hands and prepare sterile
equipment
To reduce risk of infection
3
Draw up 20mls 0.9% Sodium Chloride
into 20ml syringe using the green needle
To reduce risk of infection
4
Put on sterile gloves
To prevent cross infection
5
Place sterile dressing towel under the
patient’s arm
To reduce risk of infection
6
Clean the needle free injection port with
2 % Clorhexidine and allow to dry for 30
seconds
To reduce the risk of
infection
7
Connect a compatible Vacutainer
system/bottle holder to port with a firm
twisting motion. Attach a 6ml (yellow)
vacutainer sampling bottle and allow to
fill
Ensure removal of any saline
solution or heparin or other
intravenous medications
from the dead space that
may result in obscured blood
results
8
Remove the sampling bottle and
discard.
To prevent risk of
contamination to ensure an
accurate sample result
9
Connect the necessary Vacutainer blood
sampling tubes withdraw the necessary
amount of blood for testing.
Each vacutainer bottle
requires a specified amount
of blood for testing.
Ensure the correct order of withdrawal is
carried out
Avoids cross contamination
with mediums in the bottles.
10
Remove the Vacutainer system, clean
the needle free injection port with a new
sterile 2 % Chlorhexadine cleansing
swab
To reduce risk of infection.
11
Following blood sampling, the line
MUST BE FLUSHED with 20mls 0.9%
To create turbulence and
ensure removal of all blood
Administration by Injection Policy
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February 2014
Action
No
PROCEDURE
RATIONALE
Sodium Chloride in 20 ml syringe, using
the ‘push, pause’ method NB:
dependent on the patients specific care
plan, a second flush using heparinised
saline solution may also be required
in the catheter and prevent
occlusion
12
Replace with a new sterile needless
injection port unless otherwise stated in
patients own care plan or hospital
specific guidelines at page 67
To prevent infection
13
Dispose of equipment appropriately
As per Healthcare (Clinical)
Waste Policy
7.
Potential Complications
7.1
This list is not exhaustive and serves as a brief guide for actions to take as
what to do should problems arise. A degree of clinical judgement is called
for, but do not hesitate to report any incidents and or complications to senior
nurses and medical staff at the unit where the central line was originally
inserted. It may also be necessary for the patient to be referred back to the
original unit for further assessment.
Persistent withdrawal occlusion
7.2.
Carry out the following interventions:
•
•
•
•
•
check for kinks or constriction on the line
move patient’s arm, shoulder, and head. Change their position
attempt to aspirate blood clot (see below)
if the blockage is known or thought to be due to a clot, aspiration can
be attempted as small clots can be dislodged. This should be carried
out with heparinised saline by competent staff
NB: Under no circumstance should an attempt be made to force fluid
into the line as this may result in the clot being forced into the
circulation resulting in cerebrovascular or pulmonary embolism
Aspiration difficulties
7.3
Carryout the following interventions:
•
•
•
check for kinks or constrictions on the line
get patient to move their arm, shoulder and head, change their position
if no resistance is felt, flush vigorously with 10ml of 0.9% Sodium
Chloride
Administration by Injection Policy
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February 2014
•
•
if resistance to infusion is felt check for signs of extravasation
Seek advice from the referring unit
Bleed-back into the line
7.4
Carryout the following interventions:
•
•
•
flush line and review frequency
ensure line is kept clamped (if appropriate)
ensure all flushes end with positive pressure
Catheter damage
7.5
Carryout the following interventions:
•
•
•
•
•
line repair is possible if the split is below where the line divides i.e. near
the catheter hub
if the split is high then the catheter will need to be removed by medical
staff
determine site of damage
clamp catheter using non-toothed forceps and gauze to protect line,
proximal to damage
Seek advice from the referring unit
Displacement
7.6
Carry out the following interventions:
•
•
•
•
•
there is a risk that the line may become partially or completely
displaced. This will be indicated by: obvious line removal
detectable lengthening of the external part of the line or visibility of the
cuff
difficulty aspirating or infusing fluids
local pain swelling / pain on administration of fluids
Partial displacement
7.7.
Carry out the following interventions:
•
•
if the catheter is partially displaced there is a risk of fluid extravasation
seek advice from the referring unit
Total removal
7.8
Carry out the following interventions:
•
if the catheter falls out completely there is a risk of haemorrhage at the
cut down and exit site
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February 2014
•
apply pressure dressing and seek immediate advice from the referring
unit
Air embolus
7.9
Carry out the following interventions:
•
•
•
•
•
•
•
lie patient head down and administer oxygen if required
clamp catheter using non-toothed forceps and gauze to protect line,
proximal to damage
attempt to aspirate as much air as possible
inform medical staff
ensure injection caps are correctly fitted
ensure connections are not loose
check catheter is not damaged, e.g. holes or splits
Fluid leakage from around catheter exit site
7.10
Carry out the following interventions:
•
•
•
check for catheter damage, e.g. punctured by suture needle, trocar,
scalpel, scissors, ruptured if occluded
inform medical staff
seek advice from the referring unit
8.
MANAGING BLOCKED CENTRAL CATHETERS
8.1
In the situation of a line failing to sample blood follow the simple measures in
the algorithm on page 66. Expert advice should also be sought from the
patient’s specialist Nurse or Consultant and the patients referred back to the
originator.
9.
TOTALLY OCCLUDED CENTRAL CATHETER AND PERSISTENT
WITHDRAWAL OCCLUSION (PWO)
Occluded Lines
9.5
A totally occluded catheter is when there is an inability to infuse solutions
into or withdraw from the vascular access device.
Causes:
•
•
•
•
•
•
fibrin sheath formation
blood occlusion
drug therapy – e.g. chemotherapy agents, antibiotics and lipid residues
catheter tip or valve pressed against the vein well or valve causing
damage
too large a catheter in too small a vein
traumatic cannulation
Administration by Injection Policy
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February 2014
•
health status- malignancy, dehydration, venous compression due to
tumour or metastases, sepsis, previous history of venous access
device placement, previous history of thrombus
Preventative strategies
9.6
Adhere to recommended flushing protocols and techniques. Ensure
prophylactic therapy with an anticoagulant for patients who are more at risk.
Diagnosis
9.7.
It is important to follow the Bristol Haematology and Oncology Centre
(B.H.O.C) guidelines on the management of patients with possible Venous
Access Device Occlusions;
•
•
•
•
•
•
•
•
clinical signs and symptoms can often be absent in cases of catheter related thrombus formation. In fact, by the time clinical signs are
evident the thrombus is usually extensive
however the following warning signs may be good indicators of catheter
thrombosis
frequent infusion pump alarms
change in the ability to infuse or withdrawer from the catheter
pain and/or swelling and/or limb discolouration around the chest/
neck/shoulder area
headache
dyspnoea
pyrexia/ febrility
9.8
It is helpful to assess the cause of the occlusion by taking a history of events
leading up to the event. Accurate documentation of line care by nursing staff
is essential in order to obtain a clear record of care and history of events.
9.9
For instance, indentify when the catheter was last accessed for e.g. blood
taking, the administration of a drug and if so what drug. Was the catheter
flushed after use?
9.10
In the event of a line failing to flush or administer prescribed medication,
expert advice should be sought immediately from the patient’s specialist
Nurse or Consultant and if necessary the patient referred back to the
originator.
10.
PERSISTENT WITHDRAWAL OCCLUSION (PWO)
Definition
10.1
Persistent Withdrawal Occlusion is a common problem associated with
Venous Access Devices such as Central Venous Catheters e.g. Skin
tunnelled Groshongs and PICC’s. It can be defined as the inability to
withdraw blood back despite the fact that the catheter may be
flushing/infusing well.
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February 2014
Causes
10.2
The most common causes are Fibrin Sheaths/Tails, which are attached to
the catheter. During flushing this Fibrin Tail/Sheath moves away from the
catheter tip allowing the infusion/bolus administration to be given. However
when aspiration of blood is attempted, the Fibrin Tail/Sheath is pulled
against the tip of the catheter, covering it and preventing this aspiration.
10.3
When Persistent Withdrawal Occlusion occurs, it is essential that the
Nursing algorithm is followed closely and the patient is referred back to their
specialised unit as there may be other possible causes for a
sluggish/blocked line, which would require a different management
approach.
10.4
When suspecting persistent withdrawal occlusion staff must follow the simple
advice in the algorithm on page 66. Expert advice should also be sought
from the patient’s specialist Nurse or Consultant and the patients referred
back to the originator.
11
IMPLANTED VENOUS ACCESS DEVICE
11.1
At present, care of the implanted venous access port is patient specific and
training is provided only for the named staff caring for patients with these
ports in situ. A competency assessment for this specific device will not be
required as it is not a high risk procedure, providing those undertaking the
care and management of the venous access port have previously
undertaken training and assessment in Intravenous Administration and
management of Central Lines.
11.2
Implanted ports are used for long term access and are implanted
subcutaneously under surgical conditions (Marsden 2011). The port must
not be used for venous blood sampling.
11.3
The portacath is comprised of two components; a reservoir with a self
sealing septum which is attached to a silicone catheter. This can be either
open ended or have a Groshong valve. The port is accessed by piercing the
skin with a needle into the septum of the port reservoir. The needle is a
specific non coring needle (Huber), ordinary needles must never be used so
that when removed, this allows the septum to seal it itself (Marsden 2011).
The ports are generally inserted into the chest wall. They require minimal
care of the site as the skin is intact. When not in use they only require
monthly flushing with heparinised saline. The risk of infection is low. They
allow minimal interference with activities of daily living, such as bathing
(Marsden 2011).
11.4
The disadvantage is that when access to the port is required, it can cause
discomfort for the patient as the skin is pierced with the needle. This
discomfort can be overcome by using a topical anaesthetic gel (as
prescribed) (Marsden 2011).
11.5
The potential problems that can occur are that the needle may become
dislodged during administration causing extravasation, or misplaced during
Administration by Injection Policy
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February 2014
insertion causing infiltration into the surrounding tissue. There may also be
difficulty in aspirating blood (Marsden 2011). The port is required to be
flushed after treatment with 20 mls 0.9% sodium chloride followed with
heparinised saline. Please refer to each hospital care plan for amounts and
strengths of heparinised saline solution (Royal United Hospital Bath NHS
Trust, Care of Central Venous Access Device 2007).
11.6
Regular assessment of the port is required to check for signs of infection/
infiltration or extravasation during and following treatment.
11.7
The management of an implanted port are similar to those of any central line
and therefore asepsis must be maintained throughout the procedure.
(Marsden 2011)
12
Maintenance of the Implanted Port
12.1
Patients maybe discharged home with continuous intravenous therapy via
the implanted port. The non - coring needle (Huber) is held in place with a
transparent occlusive dressing, to maintain a barrier and prevent the needle
from moving. This may already be in place prior at time of admission to the
Trust. This must be confirmed at time of handover. Following discontinuation
of the pump, the port must be flushed with 20mls 0.9% sodium chloride
followed by heparinised saline to prevent clot formation. The port must then
be maintained and flushed with heparinised saline on a four weekly basis
when it is not in use for administration of medication (Royal United Hospital
Bath NHS Trust, Care of Central Venous Access Device).
The site does not required to be dressed routinely as the port is buried
beneath the skin, occasionally following removal of the needle, where there
maybe a small amount of blood, a small dressing is required (Marsden 2011)
13
Accessing the Port - procedure for disconnection of cytotoxic pump
and removal of needle from the port
13.1
The needle and giving set may remain in situ for 7 days, then it must be
changed (Royal United Hospital Bath NHS Trust, Care of Central Venous
Access Device 2007).
13.2
For disconnection and disposal of cytotoxic waste please refer to Appendix E
- Disconnection And Disposal Cytotoxic Infusion Pumps. All waste, needles
swabs, gloves etc. must be disposed of as per the clinical waste policy
Procedure for disconnection of chemotherapy pump, flushing and
removal of needle.
•
Equipment
3 x 10 ml syringe no smaller to prevent increased pressure
2 x 21 g needle
2 x 2% Chlorhexadine in 70% Isopropyl Alcohol cleansing wipes
20 mls 0.9% sodium chloride
Heparinised saline, please see patient specific care plan for strength
and amount
Self adhesive dressing if required
Administration by Injection Policy
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February 2014
Apron
2 pairs non sterile gloves
Action
No
1
2
3
4
Procedure
Rationale
Explain procedure to patient
To ensure the patient
understands the procedure and
gives valid consent
Wash hands thoroughly as per
Trust’s Infection Prevention Control
Policy
Put on non sterile gloves and plastic
apron
Disconnect and dispose of pump as
per protocol
To minimise contamination
To minimise risk of
contamination
To follow guidelines and
prevent risk from spillage or
contamination
As per protocol to prevent
contamination from waste
7
Remove dressing and dispose of as
cytotoxic waste
Check site for any redness or
swelling or pain
Discard gloves and apron as above
8
Wash hands thoroughly
9
Put on apron, sterile gloves and
prepare equipment
To minimise contamination
10
Draw up 0.9% sodium chloride
Used to check positioning of
needle and patency of port and
to flush reservoir ensure the
drug has been fully
administered.
11
Clean end of needleless connector
with 2% Chlorhexadine in 70%
Isopropyl Alcohol cleansing wipes
and allow to dry
12
Connect syringe to needleless
connector
13
Maintain stability of port with
forefinger and index finger whilst
flushing
14
Draw back on syringe to check for
return of blood
15
Flush the port with 20 ml of 0.9%
saline observing for swelling or
complaints of pain.
16
Following flushing, the port must be
flushed with heparinised saline
before the needle is removed.
Draw up heparinised saline (ensure
this is done after flushing with the
5
6
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Signs of developing infection
As above
As per infection, prevention
and control, hand hygiene.
To minimise risk of
contamination
Needles are not to be used,
there fore risking damage to
the catheter
To ensure port remains
stable and the needle does
not move
To check the needle is in the
correct position and that the
port is patent
To check for patency and
correct positioning and to
flush through remaining
medication that has
accumulated in the reservoir
This assists in maintaining
the patency of the port and
catheter over a period of
time, by preventing formation
of clots
February 2014
saline to prevent mix up of solutions)
Please refer to patient specific care
plan for strength and amount
Using a pulsating push/ pause
technique administer heparinised
saline finishing with positive end
pressure before removing the
syringe
Discard of syringe into cytotoxic
sharps waste
17
18
Pressing down either side of the port
with two fingers
withdraw the needle using a steady
traction, discard into cytotoxic sharps
waste immediately
19
If there is any resistance or inability
to flush contact the patient’s hospital
where treatment is being delivered
and seek advice.
20
By finishing with positive
pressure this prevents
backflow of blood and
possible formation of a clot
As per protocol
To support the port whilst
removing the needle
To prevent trauma to the skin
and reduce the risk of
needlestick injury as per
policy
To prevent injury to the
patient or damage to the port.
do not try to unblock the
port, always obtain
guidance
(Marsden 2011, Royal United Hospital Bath NHS Trust, Care of Central
Venous Access Device, 2007)
Procedure for insertion of non – coring needle (Huber) and for monthly
maintenance of patency of port and catheter
The insertion of the non – coring needle (Huber) must be performed by a
Registered Nurse trained and competent in the care and management of an
implanted venous access port. This procedure is to be carried out every 4
weeks when the port is not in use.
•
Equipment
Dressing pack
Sterile gloves
Non – coring needle (Huber)*
Chlorhexadine 2% w/v sterile aqueous solution
1x 10 ml syringes
1x 21 gauge needles
Heparinised saline, please see patient specific care plan for strength
and amount
Local anaesthetic cream, especially if the site is tender or if the port is
newly implanted (will need prescribing).
*A straight non - coring needle or an angled needle with integral extension
set maybe used, if so this will need to be flushed to prime the needle.
Action
Procedure
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Rationale
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February 2014
No.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Explain the procedure to the
patient
To ensure the patient
understands the procedure and
gives valid consent
Apply local anaesthetic cream (if
required) for approx. 30 – 60
minutes
To reduce the feeling of pain
on needle insertion
Ensure cream is prescribed
Ensure the patient is comfortable
Wash hands thoroughly, as per
policy
Locate the port and identify the
septum, assess the depth of the
port and the thickness of the skin
Choose an appropriate sizes
Huber needle (gauge and length)
Wash hands again as per policy
Open dressing pack using non –
touch technique
open sterile items onto field,
again using non touch technique
To aid comfort and allow
access to the port
To prevent contamination
In order to select the correct
length of needle
To prevent damage to the
port, accidental infiltration of
heparinised saline into
surrounding tissue and
patient discomfort
To prevent contamination
To prevent contamination
To reduce risk of
contamination and to prevent
interruptions delaying the
process
Clean hands and put on sterile
To minimise risk of
gloves
contamination
Using Chlorhexidine 2% clean the To minimise risk of
skin over the port, using in a
contamination and destroy
spiral motion, inside to outside.
skin flora
Allow to dry
Draw up heparinised saline into
Used to ensure patency is
the 10 ml syringe using a green
maintained over a 4 week
needle
period
Flush the needle (and if using,
To check for patency of
prime the extension line) with the needle and set and to
heparinised saline and expel any prevent injection of air
air
Stabilise the port between
To ensure the port is
forefinger and index finger with
stabilised and does not
the non dominant hand.
move when needle is
Holding the needle in the
inserted
dominant hand, insert the needle
into the middle of the port septum
Flush using a pulsating push/
This technique helps
pause technique administer
maintain patency and
heparinised saline finishing with
prevention of clot formation.
Administration by Injection Policy
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February 2014
16
17
positive end pressure before
removing the syringe.
Pressing down either side of the
port with two fingers
withdraw the needle using a
steady traction.
Discard of all waste as per Trust
policy
the positive end pressure
prevents backflow of blood
To support the port to
prevent it from moving
To prevent risk of
needlestick injury
(Marsden 20011, Royal United Hospital Bath NHS Trust, Care of Central
Venous Access Device 2007).
14.
COMPLICATIONS
If there are any concerns at any time, please contact the specialist unit
in charge of the patient’s care.
Needle Dislodgement – Remove needle as detailed above and arrange for
another to be inserted.
Extravasation of cytotoxic IV medication – Stop the infusion, contact the
patient’s specialist unit.
Persistent withdrawal occlusion when flushing
• Confirm the needle has not dislodged
• Check for kinks / clamps still closed on the extension set
• Request the patient to change position
• Contact the patient’s specialist unit as a clot formation may have
occurred
Blockage – The patient is referred back to their specialised unit as there may
be other possible causes for a sluggish/blocked line, which would require a
different management approach.
Port Leak – May occur if a forceful flush is attempted when the line is
blocked or if the wrong type of needle is repeatedly used damaging the
diaphragm. Diagnosis of this will need to be made at the patient’s
specialised unit.
Suspected localised infection around the port – Clean area, contact referring
specialist unit for advice. Take bloods from patient for inflammatory markers.
Under no circumstances should an attempt be made to force fluid into
venous access port. This may result in a clot being forced into the
patient’s circulation potentially causing an embolism to occur.
(Royal United Hospital Bath NHS Trust, Care of Central Venous Access
Device 2007, Marsden 2011, BHOC Guidelines 2008).
Administration by Injection Policy
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February 2014
15.
REFERENCES
Avon, Somerset and Wiltshire Chemotherapy Handbook January 2005
Update
Bristol Haematology and Oncology Centre (B.H.O.C) Guidelines for the post
insertion management of Central Venous Catheters (2008).
Royal College of Nursing, 2010. Standards for infusion therapy.
Dougherty, L and Lister. S (2011). Royal Marsden Hospital Manual of
Clinical Nursing Procedures. 8th ed. Wiley – Blackwell, Vascular Access
Devices; Insertion and Management, (Peripherally Inserted Central
Catheters, Inserted Ports)
Musgrove Park Hospital - Guideline for the Insertion and Management of
Central Venous Catheters in Adults. Weare .C, Roberts. J., (May 2013)
Royal United Hospital Bath NHS Trust - Care of Central Venous Access
Devices - Gilleece. C. (2007, reviewed 2009)
Cross reference with other procedural documents (Somerset Partnership)
Healthcare Waste (Clinical Waste) Policy 2012
Infection Control Policy
Medicines Policy
Medical Devices Policy
Hand Hygiene Policy
Administration by Injection Policy
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February 2014
APPENDIX E
CYTOTOXIC INFUSION PUMPS - DISCONNECTION AND DISPOSAL
1
Personal Protective Equipment required
1.2
The use of Personal Protective Equipment (PPE) is imperative at all times
when handling any cytotoxic products, waste and spillages, including
other contaminated waste, such as soiled linen, and bodily fluids. The use
of appropriate PPE is required to limit the level of exposure of health care
workers to the cytotoxic medications, equipment and associated waste.
1.3
Double glove with sterile gloves when handling central venous access
(PICC/Hickman line) devices and cytotoxic therapies and wear a
disposable plastic apron at all times.
Staff must ensure that the blue tray and the absorption mat are used
within the tray prior to and during the procedure.
2
Disconnection and disposal of cytotoxic infusion pump and
cytotoxic soft waste.
2.1
The infusion pump and giving set must be disposed of as a single unit
into the purple lid sharps bin provided, in accordance with the Trust’s
Protocol for Handling of District Nursing and Domiciliary Clinical Waste
and the Healthcare Waste (Clinical Waste) Policy.
2.2
Any change of needle-free intravenous connectors must also be disposed
of in the same manner.
2.3
The central venous access device must be flushed and managed
following disconnection of the infusion pump, in accordance with the
Trust’s Administration by Injections Policy
2.4
All medical devices and waste involved in this process will be hazardous
and classed as cytotoxic waste and must be disposed of appropriately as
described in the protocol.
2.5
All re-useable items, such as the plastic blue tray, must be rinsed with
cold water (to remove traces of cytotoxic agents) and then washed with
detergent and hot water (to prevent cross infection) (Infection Control
Policy).
2.6
The patient, carers and family members, must be advised on safe storage
of the sharps bin whilst it is in use. Health care staff must dispose of the
sharps bins at the nearest Community Health Hospital, in accordance with
the Trust’s Protocol for Handling of District Nursing and Domiciliary
Clinical Waste and the Healthcare Waste (Clinical Waste) Policy.
2.7
Any cytotoxic soft waste produced during treatment and for seven (7)
days after, must be disposed of in appropriate clinical waste bags. The
recommended waste bags for cytotoxic soft waste are yellow with a purple
Administration by Injection Policy
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February 2014
stripe. These can be ordered through NHS Supply Chain using the order
code MVN028. Used clinical waste bags must be disposed of for
incineration in accordance with Trust’s Healthcare Waste (Clinical Waste)
Policy and completing the SRCL form for home care services.
3
Special risk groups
3.1
It is highly recommended that breast-feeding and/or pregnant women, do
not act as caregivers for the patient during their chemotherapy treatments
and for seven (7) days following completion of treatment.
4
Spillages
4.1
All spillages must be dealt with immediately. If a spill occurs on the floor or
other hard surface, contact the service where they received their
treatment, as a specific spill kit will be required and the manufactures
instructions must be followed.
4.2
Spillage kits will be provided by the Trust where required.
4.3
Spillages that come into contact with the skin require the affected area to
be washed thoroughly with soapy water as soon as possible as per the
Trust’s Healthcare Waste (Clinical Waste) Policy 5.
TRAINING REQUIREMENTS
5.1
The Trust will work towards all staff being appropriately trained in line with
the Organisation’s Staff Mandatory Training Matrix (training needs
analysis). All training documents referred to in this policy are accessible to
staff within the Learning and Development Section of the Trust Intranet.
5.2
Clinical staff who are undertaking the disconnection and disposal of
cytotoxic infusion pumps, must have received training and competency
assessment in the following areas as directed by the Trust’s Training
Matrix:
•
•
•
•
•
•
•
5.3
medicines management training and competency assessment
anaphylaxis
drugs calculations
infection control
medical devices training and competency assessment
administration of intravenous drugs and competency assessment
care and management of central lines and competency assessment
All registered health care professionals required to administer medications
via a PGD, must ensure they have completed the PGD training and
competency assessment framework as stipulated in the Trust’s PGD
policy.
Administration by Injection Policy
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February 2014
6.
References;
HSE Information Sheet MISC615 “Safe handling of cytotoxic drugs”
Dougherty, L. and Lister. S (2011). Royal Marsden Hospital Manual of
Clinical Nursing Procedures. 8th ed. Wiley – Blackwell
Cross reference with other procedural documents (Somerset Partnership);
Administration by Injection Policy
Hand Hygiene Policy
Healthcare Waste (Clinical Waste) Policy 2012
Infection Control Policy
Learning Development and Mandatory Training Policy
Medicines Policy
Training Prospectus
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February 2014
ALGORITHM FOR SUSPECTED PERSISTANT WITHDRAWAL OCCLUSION
Fluids can be infused freely by gravity but blood cannot be withdrawn from the
catheter
Blood return is absent
Flush central venous
catheter with 0.9% sodium
chloride in 10 ml syringe
using brisk ‘push-pause’
technique
Ask patient to cough,
deep breath, change
position, stand up or lie
with foot of bed tipped up.
Ascertain possible cause
Blood return obtained – use
central venous catheter as
usual
Blood return is still
absent
Check for flashback of blood
Patient to receive highly
irritant/vesicant drugs
chemotherapy
Blood return is still absent
NO
Proceed if happy to do as
long as there are no other
complications or pain
YES
The following steps should initially be done
prior to drug administration and
documented in the patient’s care plan and
evaluation record so that all nursing staff
are aware that patency has been verified.
All patients require referring back to the
specialist acute hospital for further
management.
Royal College of Nursing, (2010) “Standards for infusion therapy”.
Administration by Injection Policy
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February 2014
DIFFERENCES BETWEEN HOSPITALS FOR CENTRAL LINE MANAGEMENT
ACTION
MPH
Beacon Centre
01823 333444
RUH
William Budd ward
01225 425092
Every 1 -2 weeks or
Every week or more
more frequent if soiled frequent if soiled or loose
or loose
Flush with 10mls saline
Hickman line blood Withdraw 5mls blood
and discard
Withdraw 10mls blood and
taking
discard
10mls Sodium Chloride
Once within each 7
Hickman line
day period, with 20mls followed by flush with 5mls
flushing
heparinised saline after
saline* for Groshong
each intermittent use and
type line
(If more than one
on completion of continuous
lumen each should
infusions.
Or 20mls saline if
be flushed
Twice weekly when not in
open ended line
individually)
use with heparinised saline
Bionector,
Bionectors change weekly
Hickman needleless
change weekly
connector
Every 7 days, with
Weekly unless damp or
Hickman dressing
IV3000
soiled
change
20mls saline
Lumens not in continuous
PICC line flushing
use-flush every 7 days with
minimum of 10mls of 0.9%
(Ensure correct
saline using push/pause
technique)
technique
Change of statlock
device
PICC line blood
taking
Withdraw 5mls blood
and discard
PICC dressing
change
Every 7 days, with
IV3000
Administration by Injection Policy
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Flush with 5mls 0.9%
sodium chloride
Withdraw 5ml blood and
discard
Weekly unless damp or
soiled
YDH
Maria Ormisher
01935 475122
Manufacturer
recommendations
Every 3 weeks or more
frequent if soiled or loose
weekly
Withdraw 3-5mls blood
and discard
Once weekly with 10mls
0.9% Sodium Chloride
and 2mls heparinised
saline – DW Yeovil and
they are happy for us to
flush weekly in
community
Bionectors change every
7 days
Every 7 days
When not in use every 7
days,
10mls 0.9% Sodium
Chloride
Withdraw 2-5mls blood
and discard
Weekly unless
soiled/loose/damp
February 2014
PICC needleless
connector
Cleaning ports
Bionectors
Change weekly
CLC 2000 change weekly
2% Chlorhexadine in 2% Chlorhexadine in 70%
70% Isopropyl Alcohol Isopropyl Alcohol wipes
wipes
Chloraprep
Chloraprep
Skin cleansing at
dressing change
Sterile
Use of gloves for
dressing change and
hub change
Non touch non sterile
Glove use for
flushing and blood
taking
with IV 3000
Bionectors change
weekly
BD 100 uses
2% Chlorhexadine in
70% Isopropyl Alcohol
wipes
Chloraprep
Sterile
Sterile
Non touch non sterile
Sterile
Open ended lines will usually have a positive pressure device.
Groshong type lines may only have a bionector device where manual positive pressure flush technique is required
Administration by Injection Policy
V5
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February 2014
CENTRAL LINE MANAGEMENT EVALUATION RECORD
Patient Name...........................................................
Date of Birth...........................................................
NHS Number...........................................................
Type of Central Line...............................................
Date of insertion of line and length on insertion............................................................................
INTERVENTIONS
DATE
External
line length
(cm)
Exit site
condition
Administration by Injection Policy
V5
Site
cleaned
and
dressing
changed
SteriStrips
changed
- 57 -
Statlock
device
changed
Needle
free port
changed
Comments
(include blood sampling,
PWO/occlusion problems
February 2014
Review
Date
Name and
Signature
INTERVENTIONS
DATE
External
line
length
(cm)
Exit site
condition
Administration by Injection Policy
V5
Site
cleaned
and
dressing
changed
SteriStrips
changed
- 58 -
Statlock
device
changed
Needle
free port
changed
Comments
(include blood sampling,
PWO/occlusion problems
February 2014
Review
Date
Name and
Signature
APPENDIX F
COMPETENCIES FOR THE ADMINISTRATION OF INTRAVENOUS (IV) DRUGS
The competencies are to be used in conjunction with: •
•
•
•
•
•
Musgrove Park Hospital Intravenous Drug Monographs (via T&S Intranet)
Nursing and Midwifery Council (NMC) (2008) The Code: standards for conduct;
performance and ethics for nurses and midwives
NMC (2007), Standards for Medicines Management, updated 2010.
NMC (2007) Standards to support learning and assessment in practice. NMC
standards for mentors, practice teachers and teachers.
Royal Marsden Manual of Nursing Procedures (eighth edition) 2011.
Royal College of Nursing (RCN) (2010) Standards for Infusion Therapy.
Somerset Partnership Policies:
•
•
•
•
•
•
•
•
Administration by injection Policy
Community Health Protocol for Assessing Competency in Clinical Practice
Consent to Examination or Treatment Policy
Healthcare (Clinical) Waste Policy
Infection Prevention and Control Policy
Needlestick and Contamination Injury Policy
Record Keeping and Records Management Policy
Syringe Driver Policy
The purpose of these competencies is to clarify the knowledge and skills expected of
practitioners, to ensure safe practice in administering IV Medications.
Once the practitioner has reached a satisfactory level of competence following a period
of supervised practice, ensure they are formally competency assessed - within three
months of completing the initial theoretical/practical training.
The self–rating scale is to be used by the individual practitioner for self assessment of
present performance during supervised practice, and to help identify learning needs.
Their line manager, or other experienced practitioner, must then assess these skills and
sign to confirm competency.
Only qualified practitioners with a NMC recognised teaching and assessing in practice
qualification and who have completed recognised training and assessment in
administering intravenous drugs can be identified as assessors.
Key for Self-Assessment
1 = No knowledge / experience
2 = Some knowledge / experience
Administration by Injection Policy
V5
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February 2014
3 = Competent
4 = Competent with some experience
5 = Competent, experienced and able to teach others
A competence level of 3 or above must be achieved prior to practising
unsupervised
Author
Jaime Denham
Nina Vinall Senior Nurse for Clinical Practice
Date
May 2012
Review
October 2015
Administration by Injection Policy
V5
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February 2014
ASSESSMENT OF COMPETENCY FOR IV DRUG ADMINISTRATION
I confirm that I have self-assessed as competent to practice Intravenous Drug
Administration as below:
Practitioner Name:
………………………………………………
Practitioner Qualification: ………………………………………………
Practitioner Signature:
………………………………
Date: ………………..
I confirm that I have assessed the named practitioner above as competent to
perform the above skill.
Name & Title:
………………………………………………
Signature:
………………………………
Date: ……………….
It is a requirement that competence in this skill is reviewed annually at PDP.
Upon successful completion of your assessment of competency please send to
your line manager and retain a copy for yourself.
Administration by Injection Policy
V5
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February 2014
Knowledge and Skills for
Administration of IVs
1
2
3
4
List 6 potential hazards of IV
therapy
For each hazard identified
above, describe how the risk
may be reduced or avoided,
and how you would manage
this hazard if it should occur
Identify correct procedure for
managing and reporting
needlestick incidents
Identify the correct
maintenance and care of
intravenous infusion devices
Self Assessment
Formal Assessment
Score
Signature
Tick
Date & Comments
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
Administration by Injection Policy
V5
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February 2014
Date & Comments
Knowledge and Skills for
Administration of IVs
5
6
7
8
Calculate
drug
dosage
correctly and show evidence of
passing calculation test
Prepare equipment and drugs
safely demonstrating aseptic
technique and correct use of
personal protective equipment
Check site for signs of phlebitis
and for patency.
Administer medication safely
and competently, within IV
policy.
Self Assessment
Formal Assessment
Score
Signature
Tick
Date & Comments
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
Administration by Injection Policy
V5
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February 2014
Date & Comments
Knowledge and Skills for
Administration of IVs
9
Safely dispose of equipment
Self Assessment
Formal Assessment
Score
Signature
Tick
Date & Comments
1
2
10
Record information correctly on
patient / client documentation,
including reporting effectively
any adverse reactions
recognised.
Administration by Injection Policy
V5
- 74 -
3
4
5
1
2
3
4
5
February 2014
Date & Comments
APPENDIX G
COMPETENCIES FOR THE CARE OF CENTRAL LINES AND PERIPHERALLY
INSERTED CENTRAL CATHETERS (PICC) AND HICKMAN LINES
The competencies are to be used in conjunction with: •
•
•
•
•
•
Musgrove Park Hospital Intravenous Drug Monographs (via T&S Intranet)
Nursing and Midwifery Council (NMC) (2008), The Code: standards for conduct;
performance and ethics for nurses and midwives.
NMC (2007), Standards for Medicines Management.
NMC (2007) Standards to support learning and assessment in practice. NMC
standards for mentors, practice teachers and teachers.
Royal Marsden Manual of Nursing Procedures (eighth edition) 2011.
Royal College of Nursing (RCN) (2010) Standards for Infusion Therapy.
Somerset Partnership Policies:
• Administration by injection Policy
• Assessing Competency in Clinical Practice (Community Health) Protocol
• Consent to Examination or Treatment Policy
• Healthcare (Clinical) Waste Policy
• Infection Prevention and Control Policy
• Medicines policy
• Needlestick and Contamination Injury Policy
• Record Keeping and Records Management Policy
• Syringe Driver Policy
The purpose of these competencies is to clarify the knowledge and skills expected of
practitioners, to ensure safe practice in the care of central lines and PICC lines. The
practitioner must have already been assessed as competent in IV drug administration.
Once the practitioner has reached a satisfactory level of competence following a period
of supervised practice, ensure they are formally competency assessed - within three
months of completing the initial theoretical/practical training.
The self–rating scale is to be used by the individual practitioner for self assessment of
present performance during supervised practice, and to help identify learning needs.
Their line manager, or other experienced practitioner, must then assess these skills and
sign to confirm competency.
Only qualified practitioners with a NMC recognised teaching and assessing in practice
qualification and who have completed recognised training and assessment in managing
central lines, PICC and Hickman lines, can be identified as assessors.
Administration by Injection Policy
V5
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February 2014
Key for Self-Assessment
1 = No knowledge / experience
2 = Some knowledge / experience
3 = Competent
4 = Competent with some experience
5 = Competent, experienced and able to teach others
Author/s: Jaime Denham Clinical Skills Facilitator (East)
Nina Vinall Senior Nurse for Clinical Practice
Date
: February 2012
Review : October 2015
Administration by Injection Policy
V5
- 76 -
February 2014
ASSESSMENT OF COMPETENCE FOR CARE OF CENTRAL LINES
AND PERIPHERALLY INSERTED CENTRAL CATHETERS (PICC)
AND HICKMAN LINES
I confirm that I have self-assessed as competent to care for:
Hickman Lines
Peripherally Inserted Central Catheters
(Tick all that apply)
Practitioner Name:
………………………………………………
Practitioner Qualification: ………………………………………………
Practitioner Signature:
………………………………
Date: ………………..
I confirm that I have assessed the named practitioner above as competent to
perform the above skill.
Name & Title:
………………………………………………
Signature:
………………………………
Date: ……………….
Upon successful completion of your assessment of competency please give a
copy to your line manager and keep a copy four own professional portfolio
Administration by Injection Policy
V4 .3
- 77 -
January 2014
Knowledge and Skills for
Central lines
1
2
Demonstrates an
understanding of the nature of
central lines, different types in
use and their indications for
use.
List 4 main hazards for patients
with central lines and the signs
and symptoms of each of these
hazards.
Self Assessment
Score
Tick
Date & Comments
1
2
3
4
5
1
2
3
4
5
3
4
For each hazard identified
above, describe how the risk
may be reduced or avoided,
and how you would manage
this hazard if it should occur.
Understands the principles of
asepsis in relation to care of
central lines.
1
2
3
4
5
1
2
3
4
5
Administration by Injection Policy
V4 .3
- 78 -
January 2014
Formal Assessment
Signature
Date & Comments
Knowledge and Skills for
Central lines
5
6
Demonstrate an awareness of
the differences in central line
management procedures
between the 3 main acute
District General Hospitals:
• frequency of needless
connector changes
• frequency of dressing
changes
• frequency of statlock
changes (if used)
Demonstrates correct
technique in flushing the
device, administering
prescribed medication and
using the correct equipment.
Self Assessment
Score
Tick
Date & Comments
1
2
3
4
5
1
2
3
4
5
7
Demonstrates competence in
obtaining blood samples from a
central line with different
recognised sampling methods.
1
2
3
4
5
Administration by Injection Policy
V5
- 79 -
February 2014
Formal Assessment
Signature
Date & Comments
Knowledge and Skills for
Central lines
8
Demonstrate knowledge and skill
in preventing line occlusion
following blood sampling
Self Assessment
Score
Tick
Date & Comments
1
2
3
4
5
9
Demonstrates competence and
understanding of the correct
dressing procedure for:
1
•
3
•
Skin tunnelled (i.e. Hickman)
lines
PICC lines
2
4
5
10
Demonstrates safe handling and
correct disposal of sharps.
1
2
3
4
5
Administration by Injection Policy
V5
- 80 -
February 2014
Formal Assessment
Signature
Date & Comments
Knowledge and Skills for
Central lines
11
12
Recognises the patients and the
family’s need for information and
education in relation to:
• The principles of hygiene
and care of the line.
• Symptoms/problems to
observe for.
Action to be taken if problems
arise.
Demonstrates the importance of
accurate record keeping and
correct documentation.
Self Assessment
Score
Tick
Date & Comments
1
2
3
4
5
1
2
3
4
5
Administration by Injection Policy
V5
- 81 -
February 2014
Formal Assessment
Signature
Date & Comments
Appendix H
SAFER USE OF INJECTABLE MEDICINES PRACTICE STANDARDS
(Derived from NPSA Patient Safety Alert No 20
And Medicines Policy)
Agreed by Practice Standards Group 16/03/2009
Updated/Reviewed by Practice Standards Group 19/09/2011, 14/11/2011
Relevant Policies: Medicines Policy, Infection Control Policy, and the Rapid Tranquillisation Guidelines
9
Service area(s) to which standards apply :
Standards and policy due for review
October 2013
Audit regularity
12 months
Previous audits
None
Administration by Injection Policy
V4.3
All
Community Adult
All Inpatient Wards
Community Older
Inpatient Adult
CAMHS
Inpatient Older
Eating Disorders
Rehab & Recovery
Learning Disabilities
- 82 -
January 2014
INJECTABLE MEDICINES AUDIT STANDARDS
Ref
No
Standard
Compliance
Exceptions
Definitions
None
Includes in-patient prescription charts and
discharge and leave prescriptions. Prescriptions
should be expressed as x days or x weeks (not
in abbreviations such as 1/12 or 2/52 and not as
two weekly which could be misread as two
prescriptions a week).
Prescribing Injections
1
2
For injections not administered on a
daily basis the frequency must be
expressed in unambiguous terms, on
hand written prescriptions.
Prescriptions for injectable medicines
must state the route of administration.
100%
Includes in-patient prescription charts and
discharge and leave prescriptions.
100%
None
100%
Where there is no ready
to use product available.
A separate prescription must be written for each
route of administration.
Preparing Injections
3
Ready to administer products should be
used
Administration by Injection Policy
V4.3
- 83 -
Ready to administer product requires no
preparation.
January 2014
4
Ampoules or vials must not be used to
prepare more than one injection.
100%
Products specifically
labelled by manufacturer
for multi-dose use.
5
Injections should only be prepared by
healthcare staff who understand the
risks involved, and are able to
demonstrate their competency for the
task
100%
None
None
None
Injections should normally be prepared and
administered in a clinical area on Trust premises.
After a full risk assessment a different location
may be agreed. Use disposable cardboard tray if
injection prepared in non-clinical environment.
None
Information must be available about the product
and processes needed for safe preparation and
administration. Sources include the product
package insert, IM injection monographs
available from Medusa on Trust intranet.
6
Injections should be prepared in a clean
and uncluttered environment.
7
Injections should only be prepared when
a prescription and appropriate
information about the product are
available.
100%
100%
Checks will include:
8
Appropriate checks must be made prior
to preparing an injection
100%
•
•
None
•
Administration by Injection Policy
V4.3
- 84 -
Prescription relates to person to be treated
Selection of the correct product, strength and
formulation
Expiry date of product and any damage to
vial, container or packaging
January 2014
•
•
Appropriate infection control measures
and aseptic non-touch technique (ANTT)
must be used when preparing injections
9
10
Injections should be administered
immediately after preparation
11
When administering more than one
injection at the same time injections
must be prepared and administered
separately, only one unlabelled medicine
handled at one time and injections must
not be mixed together in the same
syringe
Medicine stored as recommended e.g.
refrigerator
Patient has no known allergy to medicine or
suffered a previous adverse reaction
100%
None
Infection control measures include cleaning
hands, wearing disposable protective gloves,
using universal cleaning wipe to clean and
disinfect surface. Do not put down syringes
attached to an unsheathed needle.
100%
In exceptional
circumstances injections
can be labelled at time of
preparation for
administration later.
Immediately means no interruption in the
process between preparation and administration.
When labelling syringes, Trust syringe labels
must be used and all details must be completed.
100%
Injections may be mixed
together if there is
specific information
confirming compatibility in
None
either the product insert
or IM injection
monograph available from
Medusa
100%
IM Risperidone is now
licensed for deltoid
administration. Other
injection sites may be
Administration
12
IM injections will be given into
dorsogluteal or ventrogluteal sites using
the Z track technique
Administration by Injection Policy
V4.3
Details of Z track technique available in policy
- 85 -
January 2014
used if specified by
prescriber on the
prescription
All key parts (those that will have direct contact
with or break the patient’s skin) should be sterile
at the point of use.
All parts of the syringe and needle will be of the
single use disposable type.
13
14
All injections should be administered
using an aseptic non-touch technique to
ensure that only sterile parts touch or
breach the patient’s skin
Depot antipsychotic injections must be
administered within 48 hours either side
of the due date
Administration by Injection Policy
V4.3
100%
100%
Any visible dirt should be removed from the skin
prior to administration using soap and water.
There is no clear evidence to support the routine
use of an alcohol swabs prior to injection,
however if further disinfection of the site is
deemed clinically necessary, a 70% alcohol
swab should be rubbed over the site using
adequate force for at least 30 seconds and the
area allowed to dry prior to administration.
None
Record the reason why the administration date
has altered in the patient’s electronic record.
When administration occurs more than 48 hours
earlier or later than prescribed details recorded
must include whether the prescription is to be
rescheduled thereafter. If it is more than 48
hours, the prescription chart should be updated
accordingly.
None
- 86 -
January 2014
Appropriate action includes
15
Patients should be monitored for any
adverse effects following administration
and appropriate action taken if they
occur
100%
Community patients
where monitoring is only
indicated if a depot is
initiated or changed.
•
•
•
Recording possible adverse effects in the
patient’s electronic record,
Informing the prescriber or a doctor at the
earliest opportunity
Reporting specified reactions reported to the
MHRA using yellow card system.
Community patients or carers should be
provided with appropriate information
about their injection
100%
16
Information must include potential adverse
effects and advice on appropriate action to take if
they occur
None
Disposal
17
All staff administering injections should
have immediate access to an
appropriate sharps container.
Administration by Injection Policy
V4.3
100%
If the sharps are to be used away from the clinic
room environment, a smaller ‘community’ type
box should be used which has a temporary
closure facility.
None
The box should be temporarily closed whenever
the box is moved or carried.
- 87 -
January 2014
All sharps boxes should be of the ‘Daniel’s’ type
Re-sheathing of needles should never occur.
18
All sharps must be disposed of, intact, at
the point of use.
100%
Needles/syringes should never be
broken/dismantled/bent or processed in any way
prior to disposal.
None
The user is solely responsible for disposal of the
sharp.
Used sharps should never be carried in anything
other than a temporarily closed sharps box.
Administration by Injection Policy
V4.3
- 88 -
January 2014